[Senate Hearing 107-407]
[From the U.S. Government Publishing Office]
S. Hrg. 107-407
CAPACITY TO CARE IN A WORLD LIVING WITH AIDS
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HEARING
BEFORE THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
EXAMINING ISSUES RELATED TO HEALTH CARE FOR PATIENTS WITH THE AIDS
VIRUS AND WHAT CAN BE DONE TO ADDRESS THE GLOBAL HIV/AIDS PANDEMIC
__________
APRIL 11, 2002
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Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut JUDD GREGG, New Hampshire
TOM HARKIN, Iowa BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington PAT ROBERTS, Kansas
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York MIKE DeWINE, Ohio
J. Michael Myers, Staff Director and Chief Counsel
Townsend Lange McNitt, Minority Staff Director
C O N T E N T S
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STATEMENTS
APRIL 11, 2002
Page
Kennedy, Hon. Edward M., a U.S. Senator from the State of
Massachusetts.................................................. 1
Clinton, Hon. Hillary Rodham, a U.S. Senator from the State of
New York....................................................... 1
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee..... 5
Murray, Hon. Patty, a U.S. Senator from the State of Washington.. 11
Warner, Hon. John, a U.S. Senator from the State of Virginia..... 11
Dodd, Hon. Christopher J., a U.S. Senator from the State of
Connecticut.................................................... 12
Sessions, Hon. Jeff, a U.S. Senator from the State of Alabama.... 14
Thurman, Ms. Sandra L., president, International AIDS Trust,
Washington, DC................................................. 14
Prepared statement........................................... 17
John, Sir Elton, chairman, Elton John AIDS Foundation, Beverly
Hills, CA...................................................... 20
Prepared statement........................................... 22
Mugyenyi, Peter, M.D., director, Joint Clinical Research Center,
Kampala, Uganda................................................ 24
Prepared statement........................................... 26
Rosenfield, Allan, M.D., dean, School of Public Health, Columbia
University; director, MTCT-Plus Initiative, New York, NY....... 27
Prepared statement........................................... 30
Dortzbach, Ms. Deborah, international director, HIV/AIDS
Programs, World Relief International, Baltimore, MD............ 32
Prepared statement........................................... 34
CAPACITY TO CARE IN A WORLD LIVING WITH AIDS
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THURSDAY, APRIL 11, 2002
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 10:38 a.m., in
room SD-106, Dirksen Senate Office Building, Hon. Edward M.
Kennedy (chairman of the committee) presiding.
Present: Senators Kennedy, Dodd, Wellstone, Murray,
Clinton, Frist, Warner, and Sessions.
Opening Statement of Senator Kennedy
The Chairman. The hearing will come to order.
We welcome our guests this morning who bring to this issue
the challenges that we are facing in international AIDS a
wealth of experience and an extraordinary sense of compassion
and a series of recommendations about how we as a country can
be even more effective in giving this the kind of world
priority that it deserves.
I am going to recognize Senator Clinton, whose schedule is
complicated, and who has been a real leader in our committee on
this issue as she is on many other issues, and then I will say
a word about some of my colleagues.
Senator Frist has been a great leader. He has traveled to
Africa a number of times and has been very much involved in
this issue as well as in other health issues. We are obviously
very, very grateful for his presence and involvement.
Senator Warner has been a very active supporter of all of
these efforts and very much wanted to have the opportunity to
listen to our witnesses as well.
In just a moment, I will also talk about the leadership
that has been provided by other colleagues on other committees
which has been so valuable and helpful, but I want to extend
just a word of very special appreciation to the leadership that
Senator Clinton has provided. We are enormously grateful for
her words at this time.
Opening Statement of Senator Clinton
Senator Clinton. Thank you very much, Mr. Chairman.
I think we can tell by the number of people who are here
that this issue has enormous impact here in our country and
around the world, and I am very grateful to all the witnesses
who are here and particularly pleased that my friend and
someone who has really led with his own charitable giving, the
effort to deal with HIV/AIDS, Elton John, could be with us
today. I asked Chairman Kennedy if we could just put a piano in
here, and he could sing his testimony, but we did not get that
worked out in time--maybe the next time.
We are also grateful to Sandra Thurman, who is president of
the International AIDS Trust, for working in this area for so
many years, and Dr. Allan Rosenfield from Columbia University
in New York. And indeed, we are also grateful to Dr. Mugyenyi
and also our last witness, Deborah Dortzbach.
All of these people represent the most forward-looking,
effective advocacy and practice when it comes to HIV/AIDS. I am
delighted that this hearing is being held by this committee,
because we know that we have to have a united effort in our
country. I want to thank Senator Frist for working with me on a
bill that we introduced last year which really follows up on
the work that he has done for so many years in Africa. This
bill would send more trained doctors and nurses and health
professionals to countries where we could help to provide
additional resources, both money and human, in the great
struggle against HIV/AIDS. So I appreciate not only Senator
Frist's leadership but his example.
Having a trained, stable work force is one of the keys, but
clearly, that is not enough. I would hope that the United
States' efforts would be significant. In the United States,
roughly 70 percent of the $10.8 billion of Federal resources
spent on HIV/AIDS over the years has gone to care and
treatment. Globally, the percentage of dollars spent on care
and treatment is only 10 percent. We have to have a much
broader range of reaction that takes into account all the
various challenges that we confront.
I appreciate Secretary-General Kofi Annan's call for a $10
billion investment worldwide. I think, as a Senator who
represents a State where we have struggled with HIV/AIDS for
years and as someone who in the previous administration was
privileged to go not only to Africa, but to Asia several times,
that the United States' fair share of this effort should be 25
percent at minimum. I do not think that we have stepped up and
given the resources that this emergency really demands from the
United States.
We also have to better utilize the extraordinary expertise
available in our Federal Government and assets in institutions
like HHS which, through its various agencies--HRSA, CDC, NIH--
over which this committee has jurisdiction, has tremendous
expertise that needs to be utilized. HHS has been a key partner
in the so-called Life Initiative since it was launched,
virtually tripling the United States' investment in
international HIV/AIDS efforts.
So today, we will look at the problem in light of what we
could do, what we could do more, what we could do better,
especially given HHS' strengths and capacities, and the
leadership that the United States should show in addressing
this global crisis.
I want to thank the witnesses and many others whom I see in
the audience who, through their hard work, their philanthropic
efforts, and their political advocacy, have really forced this
issue to the forefront of our agenda, and I thank you, Mr.
Chairman, for giving us this opportunity to really focus
national and international attention. We have a number of
ambassadors from different countries here, many from African
countries, and I am very pleased that they are here as partners
in this effort.
The Chairman. Thank you very much, Senator Clinton.
Before recognizing others, I want to thank Senator Gregg,
our ranking member, who is not here.
Our leader, Senator Daschle, has given this a very high
priority for this session of Congress. Senators Durbin,
Corzine, Feinstein, Kerry, and Biden are members of the Foreign
Relations Committee who have very, very important obligations
and responsibilities in terms of serving that committee and
also in this area. We are working very closely with them, as we
should. And we are grateful as well to the support that Senator
Helms has given to particularly the issues on infants and their
various challenges.
I will take just a very brief moment to thank our witnesses
for being here.
This is a pandemic that is affecting Africa, but not only
affecting Africa--it is expanding into India, Southeast Asia,
China, and the Soviet Union. It is something which this
committee first held hearings on over 10 years ago, and at that
time, the challenge that we faced as a country and as a society
was really riddled with ideology, not science, not health
considerations, but ideology. And it took a long time for the
United States to begin to come to grips with this issue and
deal with it in terms of understanding it, willingness to reach
out to the millions of people whose lives are so devastated and
affected by the scourge of this disease. We have made enormous
progress, and it is a real tribute to so many who have worked
so hard for so long in helping and assisting Congress and
providing leadership in local communities and States as well.
The challenge is out there in terms of the world, and the
real challenge is will the United States really rise to this
challenge when we have been able in the last 10 years, with the
progress that has been made, the research that has been
achieved, the understanding about prevention, the new
modalities in terms of understanding the challenge that is out
in regard to mothers and infants, the reality of understanding
the devastation that this scourge causes countries in Africa--
we cannot exist on this planet without understanding how our
fellow citizens are hurting, and when the United States is
prepared to lead, what a difference it can make. We have
already seen it; there are encouraging signs.
This is really a wakeup call, and we have individuals on
our panel this morning who will help us better understand it,
and I am most grateful to all of them, as they have been
leaders on this issue day in and day out over such a long
period of time. They bring a wealth of understanding, a strong
commitment, and they have been incredibly effective, so we can
benefit greatly from them, and we look forward to hearing from
them in just a moment.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Kennedy
Today's hearing is about the greatest global public health
threat of our times--the spread of HIV/AIDS.
AIDS is the fourth leading cause of death in the world.
This terrible disease destroys lives, denies hope to
individuals and families, and threatens the well-being of
entire countries.
We in America know of the pain and loss that this disease
cruelly inflicts. Millions of our fellow citizens--men, women,
and children--are infected with HIV/AIDS. And far too many have
lost their lives.
While we still seek a cure to AIDS, we have learned to help
those infected by the virus to lead long and productive lives
through the miracle of prescription drugs.
But this disease knows no boundaries. It travels across
borders to infect innocent people in every continent across the
globe.
We have an obligation to continue the fight against this
disease at home. But we should also share what we have learned
to help those in other countries in this life-and-death battle.
And we must do all we can to provide new resources to help
those who cannot afford today's therapies.
This committee and its members have a deep commitment to
sharing the lessons learned in helping our people at home to
help others meet great human needs abroad. As we sought to
enforce child labor laws at home, we also worked to protect
children abroad. As we developed new ways of promoting
children's health and public health, we have shared these life-
saving discoveries with other countries in need.
And once again, we are called upon to open the doors
between nations to do all we can to halt the spread of AIDS,
and to treat those infected by it.
Twelve years ago this month, the members of this committee
demonstrated their commitment to the care and treatment of
Americans living with AIDS by passing the Ryan White Care Act.
Since that time, community-based care has become more
available, drug treatments have improved that nearly double the
life expectancy of HIV positive individuals, and public
campaigns have increased awareness of the disease. Yet,
advances such as these remain largely the privilege of wealthy
nations.
AIDS inflicts a special toll on developing countries.
Globally, 40 million people have HIV/AIDS, and the overwhelming
majority live in poor countries. Sub-Saharan Africa is the most
affected region, where nearly all of the world's AIDS orphans
live. AIDS robs poor countries of the workers they need to
develop their economies. They lose teachers needed to combat
illiteracy and train their workers for modern challenges. In
Africa, they have lost seven million farmers needed to meet the
food needs of entire nations. AIDS plunges poor nations into
even deeper, more desperate poverty.
The presence of HIV/AIDS poses a particularly serious
concern for women and girls. Most new infections are among
young adults and women. Females who are not infected feel the
impact, too. Girls must often leave school to assume
responsibilities for sick family members, robbing them of
educational opportunities and denying local economies of
valuable workers.
Governments can make the difference in battling this
epidemic. Where governments in poor countries have been
provided resources to fight the spread of AIDS, infection rates
have dropped 80 percent. But these countries cannot turn the
corner on AIDS on their own. Their governments must be provided
the guidance and resources to carry out anti-AIDS campaigns.
They need financial help to afford expensive anti-retroviral
drugs. And drug companies must do their part to make these
drugs more affordable to the poor.
In addition, more public education is needed. A UNICEF
survey found that most young people still have not heard of
AIDS or do not understand how the disease is transmitted. By
speaking out, our Government can help to lift the stigma and
taboo surrounding the disease and save lives.
These challenges are not insurmountable. The epidemic is in
its early stages. In most regions of the world, the prevalence
rate is still less than 1 percent of the population. But we
cannot delay. It only took 10 years for the HIV/AIDS population
to double in the Russian Federation. And in South Africa, the
rate increased from 1-in-100 people to 1-in-4 in one decade.
Our committee is developing legislation to support and
strengthen global treatment and training initiatives.
Our legislation would provide new legal authority and
funding to NIH, CDC, HRSA and the Department of Labor to join
the global battle against AIDS.
It would promote community-based care models and better
access to microbicide research and retroviral therapies.
Our legislation would fund research and treatment models to
prevent the transmission of the disease from mothers to their
infants.
And it would help countries to develop better training
models that support service delivery at the grassroots level.
Today we will hear from witnesses who have devoted
themselves to fighting this epidemic by ensuring that
prevention, care, and treatment is not just accessible to some
people in some countries, but all people in all countries.
We are honored to have you with us today.
The Chairman. We have been joined by Senator Sessions and
thank him very much for joining us.
I will now turn to Senator Frist, who has been so involved
and has provided important leadership in this area, if he would
say a word.
Opening Statement of Senator Frist
Senator Frist. Thank you, Mr. Chairman.
I too want to thank each of our witnesses. It is wonderful
to be able to sit where we are and look out at the witnesses
with whom many of us have had the opportunity to interact
individually, but also to see the people who have come to this
hearing today, members from the public sector, from the
academies, from the corporate sector, from the private sector,
from the NGOs, from the evangelical community, from the
entertainment industry. It really points out to me the fact
that in 2002, we have an opportunity which, as the chairman
said, we will see if we are up to facing directly and
appropriately, but we have an opportunity to address the
challenge that has increased over the last 10 years and
increased over the last 15 years, but a challenge which is much
bigger than any of us as individuals, as Members of the United
States Senate, as members of the U.S. Government--much bigger
than the United States of America. It really is a global
challenge, and the opportunity is there before us.
This particular committee has not formally addressed this
particular issue, and I am delighted and thank the chairman and
the ranking member, Senator Gregg, for bringing this hearing
before us, because we have not formally addressed it in such a
comprehensive way in over a decade.
Over that same decade, the number of new infections of HIV,
if we look just in Sub-Saharan Africa, has increased from an
increase of around 1 million a year to around 3.5 million new
infections a year.
We have opportunities that I think are unique for the time
today because of the range of people involved. As Chairman
Kennedy pointed out, the perspective was much different 10
years ago and even 5 years ago, and as I have followed this
issue closely over the last 5 years, I think it is much
different than even a year or 2 years ago. Now it is our
challenge to capture that intersection of bringing a diverse
group of people from the breadth of the political spectrum
together to address an issue that is much greater than any of
us.
I want to thank my colleague Senator Jesse Helms who, over
the last 2 weeks, rightly said that we have within our power
the ability to substantially reduce the mother-to-child
transmission of HIV/AIDS, something that our panel will address
this morning. Senator Helms has pledged to do just that, and I
intend to join him in those efforts.
President Bush, Secretary of State Colin Powell, and
Secretary Thompson of HHS are also committed to aggressively
fighting the global AIDS epidemic.
With the commitment of our Nation's leaders and, as we will
talk about this morning, the critical importance of having
world leaders from other nations, both affected as well as
donor nations, I believe we can stand up to this challenge.
With that, Mr. Chairman, I will stop. I think that issues
and the importance of science will come forward. In the
meantime, we have a lot to do as we wait for that vaccine. We
do not even know if we are going to have that vaccine, and we
have a lot to do.
Let me just say thank you, Mr. Chairman, for calling the
hearing, and I look forward to hearing from our witnesses.
[The prepared statement of Senator Frist follows:]
Prepared Statement of Senator Frist
Mr. Chairman, thank you for calling this hearing. Senator
Clinton, I appreciate your efforts to assure that the HELP
Committee once again examines the global impact of HIV and
AIDS. It has been over a decade since this committee looked at
the topic of global HIV/AIDS, and it is critical that we
continue to highlight the impact of this disease on our global
community. This is not strictly an American problem--it ignores
national borders, threatening the entire world.
When I first came to the Senate 8 years ago, my aim was to
serve my home State of Tennessee and this great Nation. Since
arriving, my steps have also taken me far from the Senate
floor--on seven different medical mission trips to Sudan,
Africa, and most recently, in January, to Uganda, Kenya and
Tanzania.
The trips were to learn more firsthand about the impact
that a simple virus is having on the destruction of a
continent. Not a family. Not community. Not a state. Not a
country. But an entire continent.
The statistics of this global plague are shocking. Each
year, 3 million people die of AIDS. Someone dies from the
disease every 10 seconds. About twice that many, 5.5 million--
or 2 every 10 seconds--become infected. That's 15,000 a day.
And what's even more tragic is that 6,000 of those infected
each day are young--between ages 15 and 24. Ninety percent of
those infected do not know they have the disease. There is no
cure. There is no vaccine. And the number of people infected is
growing dramatically.
The disease's toll is incalculable. Thirteen million
children have been orphaned by AIDS. Over the next 10 years,
the orphan population may well grow to 40 million--equivalent
to the number of American children living east of the
Mississippi River.
As ranking member of lthe African Affairs subcommittee of
the Foreign Relations Committee, I have a commitment to
increase public awareness of the HIV pandemic in Africa, and
most importantly, to develop a strategy to combat and eradicate
the disease. What I saw and learned in Uganda, Kenya and
Tanzania was extraordinary--coming face-to-face with the human
tragedy of HIV/AIDS, and lives cut far too short.
Africa has lost an entire generation. In Nairobi, Kenya, I
visited the Kibera slum. With a population of over 750,000, 1
out of 5 of those who live in Kibera are HIV/AIDS positive. As
I walked the crowded pathways sandwiched between hundreds of
thousands of aluminum shanties, I was amazed that there were
only children or elderly individuals. The disease had wiped out
the parents--the most productive segment of the population--
teachers, military personnel, hospital workers, law enforcement
officers.
In Arusha, Tanzania, I met Margaret who developed her first
symptoms 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 6
children. I also met Nema in Arusha. 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 else to give him but her love.
I had the privilege of visiting with 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 11-year-old daughter, Adija.
At home in Tennessee, or even here in Washington, DC.,
Uganda and Tanzania feel very far away. But the plague of HIV/
AIDS and the chaos, despair and civil disorder it perpetrates
only leads to the demise of democracy in a country, in a
continent, in the world. Without civil institutions, there is
disorder.
Last year in South Africa, one of every 200 teachers died
of AIDS. In a recent study in Kenya, 75 percent of deaths on
the police force are AlDS-related. HIV-related deaths among
hospital workers in Zambia have increased 13 times in over a
decade. The aftermath of these losses is devastating to local
economies. Botswana's economy is projected to shrink by 30
percent in 10 years; Kenya's by 15 percent. Family incomes in
the Ivory Coast have declined by 50 percent, while health care
expenditures have risen by 4,000 percent.
African orphans lack teachers, lack role models and
leaders. This leaves them vulnerable to criminal organizations,
revolutionary militias, and terrorists. Terrorism and crime
could become a way of life for a young generation.
Africa is not alone. India, with over 4 million cases, is
on the edge of explosive growth. China is estimated to have as
many as 10 million infected persons. The Caribbean suffers from
one of the highest rates of infection of any region in the
world. Eastern Europe and Russia report the fastest growth of
AIDS cases.
That is why I'm devoting much of my time to this issue, and
in particular, to the impact of HIV/AIDS in Africa. Just as our
great Nation is the leader in the war on terrorism, we must
continue to lead the fight against AIDS in order to build a
better, safer world.
So, where do we go from here? There are three keys to
combating this epidemic--(1) Leadership; (2) Prevention and
Treatment; and (3) Funding.
As a first step, it takes strong leadership at all levels,
and this must come first from the top. President Museveni in
Uganda has not been bashful about speaking very publicly to the
citizens of his country about HIV/AIDS. Bakili Muluzi,
President of Malawi told me that he opens every speech to his
countrymen with an admonition about HIV/AIDS. These leaders are
acting to bring the disease into the light, to eliminate the
stigma sometimes associated with the disease. Others are
acting--governments, the United Nations, the World Bank, world
leaders, corporations and philanthropies. From President Bush
to Kofi Annan and Secretary Powell, world leaders have
recognized the call to action and the need to do more.
It is also leadership from people such as Bono, lead singer
of the Irish rock band, U2. With his passion for Africa and his
``bully pulpit'' as a celebrity, he's a credible and
accomplished spokesperson on the issue. He joined us in Uganda
and Kenya for a couple of days, and I was impressed with his
knowledge, his commitment, and his caring.
It takes leadership at all levels to ensure that our
efforts are well coordinated, understanding the importance of
the diverse stakeholders in the fight against HIV/AIDS. We must
coordinate within and across national govennments. We must
leverage our precious resources and avoid duplication of
effort. As I saw firsthand in east Africa, the best ideas often
come from those fighting this disease on the ground. Community
participation is essential, and local leadership is critical,
particularly as we work to prevent and treat the disease. Let
me cite a couple of examples.
In Tanzania, Sister Denise Lynch runs the Uhai Center for
the Roman Catholic Diocese of Arusha, serving village schools
and churches. Father Bill Freida, a physician at St. Mary's
Hospital in Kenya, tells me they serve over 400 HIV/AIDS
patients a day, and their chapel and bakery help anchor the
community. Dr. Ebenezer Mwasha, in Tanzania, teaches the
spiritual and moral values in addition to proper health and
hygiene. The work that these individuals have accomplished,
coupled with their faith and commitment, are a true
inspiration. Their efforts will pay dividends for many in the
years to come. Their leadership on the ground and in the
trenches, each and every day, is fundamental to our ultimate
success.
We should also salute the leadership of the Centers for
Disease Control and Prevention (CDC) and the United States
Agency for International Development (USAID). According to
President Museveni, our Government's investment in Uganda of
$120 million over the last 10 years has been the key to
bringing HIV/AIDS prevalence rates down from 14 percent to 8
percent. The presence of these agencies is making a difference.
Until science produces a vaccine, prevention through
behavioral change and awareness is the key. And once again,
cultural stigmas must be overcome. Through a combination of
comprehensive national plans, donor support and community-based
organizations, we can make progress. Uganda, Thailand and
Senegal are three examples of solid success.
We must encourage people to be tested. This is an
opportunity to save countless lives. The more people know, the
more likely they are to act. We should increase investments in
rapid HIV testing kits and counseling. Access to these tools
reinforces prevention messages and guides treatment options. As
I saw in Africa, testing centers become centers of hope, a
place where those struggling with HIV/AIDS support each other,
learn coping strategies, and receive medical treatment and
nutritional support.
I was particularly impressed by the work in the Kibera slum
of Nairobi at the Kibera Self-Help Programme, run by the CDC.
Officials there told me that a negative test provides a
powerful incentive to stay healthy, and gives an opportunity to
counsel people on risky behavior, ultimately saving lives. A
positive test removes the burden of uncertainty and allows for
timely treatment and counseling, an important first step in
living longer and healthier lives.
In recent months, pharmaceutical companies have sent a
message of hope by slashing prices on anti-retrovirals for poor
countries. Other treatment regimens may make an even bigger
difference in extending life and holding families together.
Just as importantly, treatment provides the hope people need to
get tested. And there are other public health advantages to
treatment that require further research and evaluation.
Treatment with anti-retroviral drugs may lower the amount of
virus in the blood, potentially decreasing the risk of
transmission, both among adults and mother-to-child
transmissions.
In addition, access to treatment and drugs is also needed
for opportunistic infections, such as tuberculosis (TB) and
malaria. For all the damage caused by HIV/AIDS, TB kills more
people in Africa with AIDS than any other opportunistic
infection. CDC officials in Kenya told me that TB has increased
six-fold in the last 10 years, and it's impossible to separate
HIV and TB. I've seen first hand in Sudan the re-emergence of
TB in strains more resistant, more virulent, than any we have
seen before. Malaria is also more rampant in the
immunosuppressed. Additionally, in treating severe anemia that
commonly accompanies illness due to malaria, untested blood
transfusions make possible additional HIV/AIDS spread.
Let me add that on the subject of vaccines we must continue
to search for the tools to reverse the spread of HIV/AIDS.
Research and development must continue, and I'm pleased to
report that NIH currently has over two dozen vaccine candidates
in the pipeline. Someday, and hopefully very soon, we will have
a vaccine to prevent this disease.
Finally, support of health care delivery systems--with a
special emphasis on personnel training--is essential to
effective treatment programs. This fundamental principle is
captured in my legislation--``the Global Leadership in
Developing an Expanded Response or GLIDER Act,'' which I
introduced last year along with Senator Clinton. The
legislation establishes the Paul Coverdell Health Care Corps--a
corps of health care professionals to assist in the development
of health care infrastructure by training local individuals.
The overall design of the Corps is such that health care
professionals throughout their career can have a wide variety
of opportunities to suit their training.
In sum, I believe there are eight goals we must pursue in
this global fight:
1. We must continue to encourage the political, religious
and business leaders of the world to unite against the spread
of HIV/AIDS and to help those who are afflicted with the
disease.
2. We must continue to embrace the new Global Fund for HIV/
AIDS, TB, and Malaria. This is not a UN fund, or an American
fund. It is a new way of doing business. As an additional show
of American support, I am joining Senator HELMS in introducing
an amendment to the Emergency Supplemental Appropriations Bill
to provide an additional $500 million to prevent mother-to-
child transmission of AIDS. These funds would be given to the
Secretary of State, who can spend them on bilateral programs
and/or give them to the Global Fund for HIV/AIDS, Tuberculosis,
and Malaria. The funds would have to be matched by non-
governmental sources.
3. We must leverage America's resources and talent. There
must be a ``call to cure'' for our health care professionals to
use their talent and expertise.
4. We must encourage and empower coalitions of governments,
multi-lateral institutions, corporations, foundations,
scientific institutions and NGO's to fill the gap between the
available resources and the unmet needs for prevention, care
and treatment.
5. We must continue to put community-based organizations,
both religious and secular, at the forefront by getting funds
to them quickly so they can most effectively reach those who
most need help.
6. We must ensure that: international research efforts on
disease affecting poor countries is reinforced in a manner that
assures the best scientific work in the world will lead to real
benefits for the developing world--at a cost they can afford.
7. We must focus on prevention, and support care and
treatment options that combine reasonable cost pharmaceuticals
with appropriately structured health care delivery systems.
8. Finally, we must provide comfort to the families and
orphans affected--to give them hope and dignity.
I can still hear young Daniel's cries of hunger and know
that his young mother will not live to see him grow into
adolescence, much less manhood; can see Sister Denise as she
patiently and capably answers my many questions about the best
ways we can help; still hear the pride in Father Freida's voice
as he describes his hospital as a place to provide dignity and
comfort to the inflicted and dying; and I think of Tabu who has
returned to her home village to face death. These images will
remain with me; they strengthen my resolve to win the fight
against HIV/AIDS.
History will judge how we as a Nation--how we as a global
community--address and respond to this most devastating and
destructive public health crisis we have seen since the bubonic
plague ravaged Europe over 600 years ago.
The task looms large, but by pulling together, with
leadership from all--we will eliminate the scourge of HIV/AIDS
from the face of the globe in our lifetime.
The Chairman. Thank you.
I will ask each of my colleagues if they want to say a
brief word.
We welcome Senator Murray.
Opening Statement of Senator Murray
Senator Murray. Thank you very much, Mr. Chairman.
Let me really thank all of our witnesses for being here
today. It is so clear that your commitment to fighting the
global AIDS epidemic and your work in developing a
compassionate and humane response really has made a difference,
so I truly want to thank all of you.
Mr. Chairman, this is such an overwhelming issue, I think,
for all of us. When you look at the number of people living
with AIDS, the number of children living with AIDS, the people
we have lost because of AIDS, it is staggering. But when you
add the number of children who are living without a parent or
parents, it becomes just overwhelming.
So I think it is very clear that we need a global response
to this growing crisis, and the United States cannot remain
passive on this issue.
So I really appreciate your holding the hearing today. I
look forward to the testimony of all of our witnesses and to
working with all of you to respond to this crisis.
The Chairman. Thank you.
Senator Warner.
Opening Statement of Senator Warner
Senator Warner. Thank you, Mr. Chairman.
I joined this committee because my father was a medical
doctor and devoted much of his life to the care of those
suffering and also to medical research.
I wish to commend you, Chairman Kennedy, Senator Clinton,
Senator Frist, for spearheading the interest here in the United
States Senate. I would take it a step further than my good
friend to my left, that it is not a challenge, but it is an
obligation for the Congress of the United States to be a full
partner in this effort.
I welcome the distinguished panel of witnesses today. You
have given much of your private and professional lives to this
endeavor.
I want to mention, Sir Elton, that a mutual friend of ours,
a longstanding friend of mine, Elizabeth Taylor, has done a lot
of work in this area, and I get frequent calls on this issue
from her.
But I have another reason that interests me. My work here
in the Senate is largely in national security and international
security, and quite frankly, this disease has had a direct
impact on many nations in Africa to be able to maintain
internal political and military stability and political and
military stability with their neighboring nations. This disease
has spread to the point where they are unable to recruit and
maintain the necessary armed forces in these respective nations
to secure their borders and otherwise.
So we must address this problem here at home, and we must
address it worldwide, and the Senate, I hope, with the Congress
as a whole will be a full partner.
Thank you, Mr. Chairman.
The Chairman. Thank you very much.
Senator Dodd.
Opening Statement of Senator Dodd
Senator Dodd. Mr. Chairman, I would ask unanimous consent
that my opening remarks be included in the record.
I want to thank Senator Clinton and Senator Frist and
others for holding today's hearing. Last evening, in fact, Mr.
Chairman, I co-chaired along with our colleague Senator DeWine
the Elizabeth Glaser Pediatric AIDS Foundation dinner, where
Morty Barr of the Communication Workers and our colleague Orrin
Hatch were honored last evening.
To try to get this in perspective, the numbers get so
overwhelming that it becomes very difficult, I think, for
average people to get a sense of the magnitude of the problem.
But I was struck, going over some of the numbers yesterday in
preparation for some brief remarks last evening, that if
everyone here just today, as we go through our normal daily
work today with our hearings and meetings and whatever else
people do, keep in mind that before the day ends, 2,000
children will contract HIV/AIDS. That happens every single
day--2,000 kids every, single day. So as we go through the
steps of what we consider a normal day, just remember that at
the end of this day, there will be 2,000 more children
infected, and that goes on every day.
So this is very, very important. I am particularly pleased
to see that we have gotten the politics out of the way on this
issue, that we are now talking about what we can do. And I
think Senator Warner is absolutely right--this is a desperate
health condition, but it also goes beyond that. It is a
national security issue, and the fact that the world is
beginning to really move on this is encouraging, and I am
anxious to hear our witnesses.
[The prepared statement of Senator Dodd follows:]
Prepared Statement of Senator Dodd
Good morning, Mr. Chairman, thank you for convening this
important hearing. I know of no greater threat to world health
today than the threat presented by EV and AIDS. A simple review
of the global numbers regarding the pervasiveness of AIDS is
staggering, Mr. Chairman. It is my hope that today's hearing
will lead us to strengthen our resolve to take on this
horrendous disease that has already robbed us of 25 million
lives since its first identification.
Here in the United States, Mr. Chairman, an estimated
850,000 to 950,000 individuals are living with the human
immunodeficiency virus, or HIV, according to the Centers for
Disease Control (CDC). An alarming one-quarter of these cases
are currently undiagnosed. Each year, more than 40,000
Americans will contract HIV, more than half under the age of
25.
An additional 338,000 Americans are living with AIDS. AIDS
is now the fifth leading cause of death in the United States
among people aged 25 to 44, and the leading cause of death for
African-American men in this same age group. However, in the
United States progress is being made. The estimated annual
number of deaths due to AIDS in the United States fell
approximately 70 percent from 1995 to 1999, from approximately
51,000 deaths in 1995 to 15,000 in 2000.
While this decrease is to be lauded, Mr. Chairman, similar
decreases in other parts of the world have unfortunately not
yet been realized. In fact, the spread of HIV and AIDS
throughout the world has grown dramatically during the same
period that the United States has decreased the toll extracted
by both HIV and AIDS.
Tragically, the Sub-Saharan region of Africa represents
only 10 percent of the world's population, but more than 70
percent of the world's HIV and AIDS-infected. More than 28
million people in this region are infected with HIV. Last year
alone more than 2.3 million Africans lost their lives to AIDS.
Since the beginning of the AIDS epidemic, Mr. Chairman, an
astonishing 19 million Africans have succumbed to this terrible
disease. In most of the world, Mr. Chairman, the overall rate
of HIV infection is 1.2 percent. Alarmingly, the same infection
rate in Sub-Saharan Africa is 8.4 percent. In sixteen African
nations, infection rates are above 10 percent and the nation of
Botswana has reached an infection rate above one-third of its
total population.
I feel I would be remiss if I didn't mention the terrible
toll that HIV and AIDS have taken on the children of Sub-
Saharan Africa. More than 12 million African children have been
orphaned since the beginning of the AIDS epidemic. Today, more
than 6.5 million AIDS orphans are living in Africa. These
orphaned children face increased risk of malnutrition and
greatly reduced access to adequate healthcare and educational
opportunities. AIDS has literally robbed millions of African
children of their parents, and too often, their futures.
Equally tragic, Mr. Chairman, is the fact that countless
numbers of children in the developing world will contract the
virus that causes AIDS through contact with their own mothers.
This year alone an estimated 500,000 children in the developing
world will contract HIV from their mothers despite the fact
that there exists already drug therapies that can virtually
eliminate mother-to-child transmission of this devastating
disease.
This is not to say, however, that the solution to the
global AIDS crisis rests solely with the availability of
lifesaving pharmaceuticals. As I know we will hear from our
witnesses this morning, just as importantly as access to
medicines in our fight against AIDS is the development of
adequate healthcare infrastructures in the developing world. We
find time and again that without sufficient healthcare
resources--such as adequately trained health professionals and
access to suitable hospitals and clinics--we will continue to
face an uphill battle that medicines alone will not win.
Mr. Chairman, again, thank you for calling this important
forum. I look forward to hearing from our witnesses this
morning.
The Chairman. Senator Sessions.
Opening Statement of Senator Sessions
Senator Sessions. Thank you, Mr. Chairman, for calling this
hearing.
It is indeed time for us to act. We have done a lot, but
much more needs to be done. I am not satisfied that any of us,
certainly myself included, number one, have been as active as
we should be in studying this disease.
I talked to Dr. Frist several years ago, telling him that
something needed to be done. He has traveled the world; he has
gone out and talked to people and utilized his great scientific
and medical expertise to help us focus on how to confront this
problem.
I certainly want to pledge my support to it. I believe that
we have got to utilize the best science possible. We know, as
Senator Dodd mentioned, that we can do more on children. That
is something we know we can do. And there are other things that
we know work with properly applied resources and scientific
work and determination.
I thank the chairman for holding this hearing and look
forward with interest to hearing the testimony of the
witnesses.
The Chairman. Thank you very much.
Just for the information of committee members, we have been
notified that there will be three votes starting at noontime,
so we have just over an hour. We will ask our witnesses if they
can limit their remarks to about 7 minutes, and that will give
each of us a chance to ask one or two questions.
Sandy Thurman, we thank you so much for all that you have
done and continue to do. We look forward to your comments.
STATEMENT OF SANDRA L. THURMAN, PRESIDENT, INTERNATIONAL AIDS
TRUST, WASHINGTON, DC
Ms. Thurman. Thank you, Mr. Chairman, and other
distinguished members.
I am delighted to once again come before the committee that
has played such a pivotal role in America's fight against AIDS.
Since the early days of the epidemic, this committee has
brought a spirit of commitment and bipartisanship to this
vitally important fight.
You have consistently demonstrated that AIDS can transcend
politics and party affiliation and that by working together, we
can make extraordinary progress. Your leadership in addressing
AIDS here at home is unparalleled, and your willingness and
commitment to fighting the pandemic around the globe is
desperately needed and very, very much appreciated. I want to
thank you all for your interest and your support.
In 1982, when I cared for my first AIDS patient as a young
hospice volunteer, I never dreamed in a million years that the
kind of agonizing death that I witnessed would not have been
stopped by the wonders of modern medicine.
A year or so later, I again found myself alone at the
bedside of a young African American man at Grady Memorial
Hospital in Atlanta who had been abandoned by his family, lost
his job and his apartment, and had almost been literally run
out of town. He wound up in Atlanta living alone in an AIDS
housing program.
I had never seen a young man fail faster than that young
man did. I will never forget the look of despair in his eyes as
his life slipped away, and I held his bone-thin hand in mine.
And while he was grateful for my presence, there was no way on
God's green earth that I could replace what he had lost. As he
called for his mother and I wiped his brow, I thought at that
moment that I would die, too. I always believed that that young
man did not really die of AIDS; he died of a broken heart that
was a complication of ignorance and fear and discrimination.
Surely, I thought at that moment in my life, we could be more
compassionate, and surely this thing would come to an end soon.
But I was wrong. The first year that I testified before
this committee, I gave more than 50 eulogies for people who
died of AIDS--a little more than one a week. The death toll was
mounting, and for those of us who were working in AIDS at that
time, it became painfully clear that there was no end in sight.
Nearly a decade later, I found myself serving in the White
House and visiting Africa to witness the epidemic there first-
hand--and there was that young man's face again, but it was
multiplied by the thousands and indeed, by the millions. It was
the first time in my professional career or my volunteer career
that I understood what the word ``plague'' really meant.
By any and every measure, AIDS is a plague of biblical
proportion. I do not have to give you all the statistics. You
know the statistics--every day, 8,000 people die of AIDS; every
day, 14,000 people become infected; and, as Senator Dodd said,
each and every day, 2,000 babies are born with HIV.
But while the challenge before us is very, very great, it
is not a cause for hopelessness and resignation, but for
leadership and action. The good news is that we know what
works. In two decades of living with AIDS, important lessons
have been learned, and effective interventions have been
developed and tested and evaluated over and over again.
Over the past few years, I have had the opportunity to
visit a dozen countries in Africa, to go to India, the
Caribbean and see first-hand the extraordinary efforts that
people on the ground are making with very, very limited
resources.
Teenagers are teaching their peers how to protect
themselves from HIV using street theater. Nuns on bicycles in
rural areas of Africa are delivering medicines to people who
need them. Grandmothers are mobilizing to care for orphaned
children in their communities. Village by village, nation by
nation, we are seeing really impressive results.
Broad-based prevention programs have stopped the epidemic
in its tracks in Senegal, dramatically slowed the spread of the
infection in Thailand, and slashed rates of new infections in
Uganda by more than half, and we are now seeing the same kinds
of results in Cambodia and Zambia.
There is much more that needs to be done, and nowhere is
the gap more glaring than in access to medical care and
treatment for the millions of poor people living with AIDS,
especially those in Africa.
If 8,000 people a day are dying of a disease for which
treatments to prolong life and reduce suffering are available,
something is terribly, terribly wrong. But the reality is that
only 5 percent of people with AIDS in Africa can even get the
most basic care--and only a few thousand on the entire
continent have access to antiretrovirals or triple-combination
therapies. And currently, while the U.S. Government is
providing some care and support, we are doing precious little
to put pills in the mouths of people who really need them. As a
global community, we can no longer sit back and watch this
happen.
I take issue with the argument that in the fight against
AIDS, we have to choose between prevention and treatment.
Survival is not an either/or proposition. Prevention and
treatment are both essential and mutually-reinforcing
strategies. We certainly learned that in the domestic epidemic
in the 1980s.
Unless treatment exists, there is little incentive for
people to come and find out their HIV status. Yet it is through
voluntary counseling and testing that some of the most
effective behavior change actually occurs. Where treatment is
offered, counseling and testing centers are literally swamped.
I know that Senator Clinton has seen that in Uganda. And as
people begin to live with AIDS, their presence in the home, in
the workplace, in the church, and in the community begins to
reduce the stigma and begins to bring AIDS out into the open
where we can deal with it head-on.
Providing care and treatment in Brazil has not only cut
their AIDS death rate by 60 percent and saved the Government
millions of dollars in hospital costs, but has helped to keep
the number of new infections to about half what had originally
been projected.
More than a decade ago, in the name of our friend Ryan
White, this committee fashioned legislation that has been a
lifeline of hope and care for millions of American families
living with HIV and AIDS. Today I urge this committee to lead
the global community in finding ways to extend that kind of
lifeline to families living with AIDS throughout the developing
world. As the committee stated in that report: ``By dedicating
this legislation to Ryan, the committee affirms its commitment
to provide care, compassion, and understanding to people with
AIDS everywhere. Ryan would have expected no less.'' That was
12 years ago.
We know the way. What we need now is the will and the
wallet to get the job done. It is not a question at this point
of whether we can or cannot--it is a question of whether we
will or whether we will not.
Mr. Chairman, Secretary Kofi Annan and UN AIDS have called
on the global community to collectively provide $10 billion a
year for HIV prevention and AIDS care programs in the
developing world. If we are going to turn the tide in this
epidemic, we have got to ratchet up our response so it begins
to match the magnitude of the challenge. The world cannot keep
trying to put out this raging fire with spoonsful of water. It
just does not work.
The Chairman. We will give you another few seconds to wind
up.
Ms. Thurman. Okay.
In fiscal year 2002, the global community is spending
approximately $2 billion, with about $800 million from the
United States. That is why 250 organizations have asked the
United States to commit the $2.5 billion that Senator Clinton
talked about to the fight against AIDS.
Mr. Chairman, I urge this committee to by a key player, to
authorize at least $400 million at CDC to expand their
essential prevention efforts, while directing new and
significant attention to care and treatment. As CDC seeks to
incorporate care and treatment in their ongoing prevention
efforts, I believe the committee should direct HRSA to do the
kind of training that they have learned so well in their
experience with the Ryan White CARE Act.
The Chairman. Just to be fair to all of our witnesses, we
will ask you to conclude, and we will include your full
statement in the record, and it was a very effective one.
Ms. Thurman. Certainly. Thank you, Mr. Chairman.
[The prepared statement of Ms. Thurman follows:]
Prepared Statement of Sandra Thurman
Mr. Chairman, Dr. Frist, Senator Clinton and other distinguished
members, I am delighted to once again come before a committee that has
played such a pivotal role in shaping America's response to AIDS. Since
the early days of the epidemic, this committee has brought compassion,
commitment and a spirit of bipartisanship to this vitally important
fight.
You have consistently demonstrated that AIDS can transcend politics
and party affiliation and that by working together we can make great
strides. Your leadership in addressing AIDS here at home is
unparalleled and your dedication to meeting the AIDS challenge around
the world is very much appreciated and desperately needed.
By any and every measure, AIDS is a plague of biblical proportion.
To date, 25 million men, women, and children have already died, and
each and every day the world loses another 8,000 lives to AIDS. And
while 40 million people are now living with HIV, today and every day,
14,000 more will become infected--one every 6 seconds. It is projected
that by the decade's end, more than 44 million children will have been
orphaned by AIDS--or nearly the same number of children as all those
attending public school in the United States.
In just a few short years, AIDS has wiped out decades of
development gains in many African nations--where infant mortality is
now doubling, child mortality is tripling, and life expectancy is
plummeting by 20 years or more.
AIDS is also having a dramatic impact on productivity, trade and
investment--striking down workers in their prime, driving up the cost
of doing business, and driving down GDP. Many businesses report having
to hire at least two workers for every one skilled job, assuming that
one will die from AIDS. Already, nurses and teachers are dying faster
than they can be replaced.
AIDS is beginning to chip away at security and stability--not just
in nations hardest hit, but among neighbors, allies and all of us.
And it is important to remember that the pandemic in Africa is just
the tip of the iceberg, with the Caribbean already seriously affected
and the fastest growing epidemics now found in India, China, and the
Newly Independent States of the former Soviet Union.
But while the challenge before us is great, it is not cause for
hopelessness and resignation, but for leadership and action. The good
news is, we know what works. In the two decades of living with AIDS,
important lessons have been learned and effective interventions have
been designed, implemented, and evaluated.
Over the past few years I have had the opportunity to visit a dozen
countries in Africa, India, and the Caribbean and to see first hand
extraordinary efforts to stem the rising tide of new infections, to
provide health care and hope to those who are sick, and to support
children and families left behind--often with very limited resources.
Teenagers are using street theatre to teach their peers how to
protect themselves from HIV. Nuns on bicycles are delivering bactrim to
people with AIDS in rural communities. Grandmothers are mobilizing to
care for orphaned children. And village by village, country by country,
in the face of seemingly insurmountable odds, we are seeing impressive
results.
Broad based prevention efforts have stopped the epidemic in its
tracks in Senegal, dramatically slowed its spread in Thailand, and
slashed rates of new infections by more than half in Uganda and now in
some populations in Cambodia and Zambia.
But there is much more that needs to be done and nowhere is this
gap more glaring than in access to medical care and treatment for the
millions of poor people living with AIDS, especially those in Africa.
If 8,000 people a day are dying of a disease for which treatments to
prolong life and reduce suffering are available, something is deadly
wrong. But the reality is that only 5 percent of people with AIDS in
Africa can get even the most basic care--and only 5,000 can now afford
antiretrovirals. As a global community we can no longer be silent about
the extent of this suffering.
I am very troubled by the argument that in the fight against AIDS
we must choose between prevention and treatment. Survival is not an
either/or proposition. Prevention and treatment are both essential and
mutually reinforcing strategies.
Unless treatment exists, there is little incentive for people to
learn their HIV status. Yet it is through voluntary counseling and
testing that some of the most effective behavior change occurs. Where
treatment is offered, counseling and testing centers are swamped,
thereby accelerating prevention. And as people begin to live with AIDS
their presence in the home, the workplace, the church, and the
community reduces stigma and begins to bring AIDS out of the shadows
where it can be fought head-on.
Providing care and treatment in Brazil has not only cut their AIDS
death rate by 60 percent, saving their government hundreds of millions
of dollars in hospitalizations, but has helped to keep their number of
new infections to less than half of what was projected.
More than a decade ago, in the name of our friend Ryan White, this
Committee fashioned legislation that has been a lifeline of hope and
care for millions of American individuals and families living with HIV.
Today, I urge this Committee to lead the global community in finding
ways to extend that kind of lifeline to families living with AIDS
throughout the developing world.
The Ryan White CARE Act fostered the development of community-based
systems of health care and support services across this country--
including many rural and resource-poor communities. In the early days,
these care networks were run by family members, community outreach
workers and volunteers, who didn't have triple combination therapies to
offer, but could offer compassion, support, treatments for
opportunistic infections, and palliative care. And these care systems
began to change the course of the epidemic in this country while we
moved to make newer and better therapies both available and affordable.
Although not directly transferable, this is precisely what needs to
happen in highly impacted countries worldwide.
It is true that we will need procurement and distribution systems,
more clinics, and more doctors, nurses, and community health workers,
more training and capacity, but that can be done. Just think--no matter
where in the world you are, you are no more than 2 minutes from a cold
Coke. That means, where there's a will, there's a way. In the meantime,
district hospitals, private sector clinics, faith-based, employer-
based, and community-based programs, and other settings provide safe
and effective places to begin delivering care and treatment.
We know the way. What we need now is the will and the wallet to get
the job done. The question really isn't can we or can't we--but will we
or won't we? I believe that the answer must emphatically be--we will--
and soon.
leadership and resources
Mr. Chairman, what we desperately need is leadership and resources.
UN Secretary General Kofi Annan and UNAIDS have called on the global
community to collectively provide $10 billion a year for HIV prevention
and AIDS treatment in the developing world. If we are going to turn the
tide, we need to ratchet up our response so that it begins to match the
magnitude of the challenge. The world can't keep trying to put out this
raging fire with spoons full of water.
In fiscal year 2002, the global community is spending approximately
$2 billion--with slightly more than $800 million coming from the United
States Government. As you can see, we are only one-fifth of the way
toward our goal. In recent days, we have been reminded of the power of
the United States to mobilize its allies against a common enemy. And no
one is in a better position to build the coalition needed to win the
war on AIDS.
That's why nearly 250 organizations have called on the United
States to move immediately toward its ``fair share'' of Kofi Annan's
``war chest''--or $2.5 billion. To take this one step further--I would
actually urge the United States to provide a ``leader's share'' of the
$10 billion--or at least $3 billion--phased-in over the next few years.
This is not a lot of money for something considered a global
priority. For example, to prevent even a single casualty from the Y2K
virus, the global community invested over $200 billion. Surely with
tens of millions, perhaps hundreds of millions of lives at stake--the
fight against AIDS deserves such an investment.
legislation: hope, care and a can-do approach
Mr. Chairman, in the context of USG leadership, there is a vitally
important role for this committee and for the departments and agencies
within your jurisdiction. As in our domestic response to AIDS, I urge
this committee to be a key player in shaping our global AIDS action by
providing significant contributions to the legislation currently being
developed by the Foreign Relations Committee.
I believe that essential components of HELP Committee legislation
should include:
Authorizing the CDC to expand essential HIV prevention efforts
while focusing new attention on AIDS care and treatment. To that end, I
would give serious consideration to a treatment set-aside which would
include a Federal match of a private initiative to expand MTCT programs
by providing the treatment needed to keep HIV+ parents alive to care
for their children.
As CDC incorporates care and treatment into their ongoing
prevention efforts, HRSA should be increasingly involved in this
process. HRSA is our health care delivery agency and its expertise
gained from administering the Ryan White CARE Act is indispensable.
HRSA also has a great deal to offer in the area of provider training
and infrastructure development--vitally important to making these
programs work in the developing world.
In addition, I would strongly urge that the Committee authorize and
push workplace-based HIV/AIDS programs through both the CDC and the
Labor Department. With 5 to 40 percent of the labor force infected in
many countries workplace prevention and treatment programs are
essential and have proven effective.
Finally, I urge this committee to work closely with the Foreign
Relations Committee on a comprehensive and coordinated global AIDS
strategy that allows the range of USG agencies to play to their
strengths and collectively maximizes the USG impact.
conclusion
In conclusion, the International AIDS Trust is extremely grateful
that this issue is receiving the broad-based bipartisan support it
deserves.
There is much hope on the horizon, but that hope will only be
realized if we join forces to save lives now. It will take a vibrant
global public-private partnership to make this happen. Nevertheless,
the pages of history are graced by times of great challenge when the
global community mobilized and made a world of difference. As one of
our board members, Archbishop Tutu, often says: ``If we wage this holy
war together--we will win.''
Let us seize the day.
With the help of those in this room we are well on our way.
Thank you very much.
The Chairman. Our next witness is someone who is enormously
gifted and talented as a singer and as a songwriter and who, a
number of years ago, because of his own deep personal interest
and concern and sense of compassion, developed a foundation.
That foundation over the period of the past years has given
more than $35 million to 55 different nations--an extraordinary
act of generosity.
This individual could be in many places around the world
today, but he has chosen to be here because of his own very
strong commitment, and he brings to this commitment both a
wealth of information and caring.
Sir Elton John, we are pleased to have you here and look
forward to your testimony.
STATEMENT OF SIR ELTON JOHN, CHAIRMAN, ELTON JOHN AIDS
FOUNDATION, BEVERLY HILLS, CA
Sir Elton John. Senator Kennedy, Mr. Chairman, thank you
very much for inviting me. I feel very honored as a British man
to be testifying to this committee, and I am very delighted to
be here with all of these great colleagues who will be
speaking.
I have worn many hats in my career . . . some of which I
have obviously regretted, but the hat of a policymaker is not
one of them. I am not going to take up your time to tell you
facts and numbers that you already know; instead, I will tell
you how I feel.
Twelve years ago last Monday, our friend Ryan White died of
AIDS. We were completely devastated, his mother Jeanne most of
all. Senator Kennedy, shortly after Ryan died, you called his
mom, and you asked her to come to Washington help pass the Ryan
White CARE Act.
Ryan White was not the first friend of mine to die from
AIDS, and he was not the last, but he taught me the most.
People shut him out of school; they shot bullets into his home;
they spread lies and slander about him. But Ryan did not hate
them. He forgave them. He knew that they were uninformed and
that they were afraid. He was troubled, though, when he gained
so much sympathy for having AIDS, because he knew it was based
on a distinction between people with AIDS who are innocent and
people with AIDS who are not. He completely rejected that
distinction.
I remember just before Ryan died, sitting at his bedside in
the intensive care unit with Jeanne, his mother. Ryan had
fallen into a coma. When Jeanne saw the tears streaming down my
face, she asked me ``What is wrong?'' and I said, ``With all of
our money, we still cannot bring this boy back to life.''
But Ryan not only moved me, he moved this committee,
because you marshalled this country's first major response to
AIDS--the Ryan White CARE Act. Thanks to your efforts, most
Americans with HIV/AIDS now have access to care and treatment.
This is a very moral and noble thing you have done. Democrats
and Republicans came together, and together you gave suffering
people hope and relief.
Over the last 10 years, through the Elton AIDS Foundation,
I have tried to do as much as I can with the money I have to
make a difference. Since 1992, we have spent more than $35
million in 55 countries, trying to eliminate prejudice against
people with HIV and AIDS, trying to educate people about how to
prevent AIDS, and trying to provide service and support to
people living with AIDS and children orphaned by AIDS.
Our first grant in Africa went to The AIDS Support
Organization in Uganda, which is now a model of excellence for
community-based programs across the continent. Our Foundation
has increased access to HIV/STD education and prevention
services for 50,000 women in slum areas of Sao Paolo, Brazil--a
program so successful that the Brazilian government is putting
up the money to double it.
We are funding the Living With AIDS Project in Thailand,
where home-based care, counseling and training encourages
villages to support--not shun--friends, relatives, and
neighbors living with AIDS. The first Elton John AIDS
Foundation grant in Russia established a help line in St.
Petersburg to provide information and counseling on HIV.
We have also established an AIDS hospice in Soweto--the
only project in Soweto providing inpatient care, day care,
outpatient care, home care, and education and training. Among
people with AIDS, the greatest fear is not of dying, but fear
of dying alone. At our hospice, no one dies alone, and we are
very proud of that.
But, Mr. Chairman, our hospice in South Africa has eight
beds, and the nation has more than 4 million people infected
with HIV. We are doing everything we can with what we have, and
we have comforted many people and saved many lives, but we have
not done nearly enough.
The people out on the front lines fighting this disease
need reinforcements, and they need them now. That means more
funding for education and prevention, more funding for
voluntary testing and counseling, more funding for care of
people with AIDS, and more funding for orphans, and it
emphatically means more access to treatment.
People with lives to lead and work to do and children to
raise must not be left to die just because they are poor. This
disease kills mothers and fathers, leaving orphans, and it
kills orphans. It will not run its course except to destroy
everything in its path.
Mr. Chairman, 95 percent of the new infections come in poor
countries. They do not have the resources to defeat it. They
desperately need your help. No nation, corporation, foundation,
or individual has the money that you have. No one even comes
close. This is the Government of the richest nation in history,
and I am here asking you for more money to stop the worst
epidemic in history.
If the United States says ``We have a moral obligation to
act,'' then other major nations will follow. I am not a student
of government, but I understand that there are two ends to
Pennsylvania Avenue, and this end controls the money.
Senator Dodd. Could you tell that to the other end?
[Laughter.]
Sir Elton John. The President cannot sign what you do not
pass. If the world is going to make a significant, decisive
intervention to change the course of this pandemic, it is going
to have to start here, and it might as well start now.
When Ryan White was asked by a reporter if he had a message
for medical researchers working on AIDS, he said: ``Hurry up.''
We all need to hurry up. Every day we delay, we lose more
lives, and we lose a little more of our own humanity.
Mr. Chairman and members of the committee, we have one
thing in common, you and I. We have all been on stage, and we
have all heard the roars of the crowd. In my line of work, if
you do not really want it to end, you can even keep it going
for a few more encores, but soon enough, the lights go up, the
crowd files out, and we all go home--and in that silence, we
are left to ask ourselves whether what we do makes any
difference at all.
When our lives are done, won't we want it to be said that
we saw millions of people suffering with disease, millions more
at risk, millions more abandoned, a whole continent in danger
of dying, and we refused to let it happen?
Mr. Chairman and members of the committee, the United
States Government is the biggest possible source of new funding
for fighting AIDS. Forty million people are infected with HIV,
8,000 people are dying every day. You have the power to end
this epidemic. Please end it. Please end it.
What American has done for its people has made America
strong. What America has done for others has made America
great. I pray that defeating AIDS will be one more great
victory that you will win for the world.
I may be reading from paper, but I really speak from the
heart. My dream as a human being is to make sure that care and
medicine are available to all human beings so that they can
live with dignity and hope. You can make this dream a reality
with your commitment to this terrible disease.
Thank you.
[The prepared statement of Sir Elton John follows:]
Prepared Statement of Sir Elton John
Mr. Chairman, and members of the committee, I've worn many hats in
my career . . . but the hat of a policymaker is not one of them. I will
not take up your time to tell you facts and numbers you already know.
Instead, I will tell you how I feel.
Twelve years ago last Monday, our friend Ryan White died of AIDS.
We were completely devastated--his mother, Jeanne, most of all. Senator
Kennedy, shortly after Ryan died, you called his mom and you asked her
to come to Washington to help pass the Ryan White Care Act. Initially,
she said no. Ryan was the spokesperson. She couldn't do that. But she
did.
The month Ryan died, this committee passed the Ryan White Care Act
that dramatically increased funding for care and treatment of people
with AIDS. Mr. Chairman, the rest of the world looks at this
legislation as a sign of what America can do for its people.
We are here today to explore what America can do for the world.
Ryan White was not the first friend of mine to die from AIDS, and
he wasn't the last--but he taught me the most. People shut him out of
school; they shot bullets into his home; they spread lies and slander
about him. But Ryan didn't hate them. He forgave them. He knew they
were uninformed and afraid. He was troubled though, when he gained so
much sympathy for having AIDS--because he knew it was based on a
distinction between people with AIDS who are innocent and people with
AIDS who are not. He completely rejected that distinction.
Over the last 10 years, through the Elton John AIDS Foundation, I
have tried to do as much as I can, with the money I have, to make a
difference. Since 1992, we have spent more than $30 million, in 55
countries, trying to eliminate prejudice against people with HIV/AIDS,
trying to educate people about how to prevent AIDS, and trying to
provide service and support to people living with AIDS and children
orphaned by AIDS.
Our first grant in Africa went to The AIDS Support Organization in
Uganda, which is now a model of excellence for community-based programs
across the continent. I am delighted Noerine Kaleeba is here to tell
you about it. Our Foundation has increased access to HIV/STD education
and prevention services for 50,000 women in slum areas of Sao Paolo,
Brazil--a program so successful the Brazilian government is putting up
the money to double it. We are funding the Living With AIDS project in
Thailand where home-based care, counseling and training encourage
villages to support, not shun, friends, relatives and neighbors living
with AIDS.
We are reaching women in India with reliable information,
affordable condoms and medical care, along with counseling about
alternative job opportunities.
We have also established an AIDS hospice in Soweto the only project
in South Africa providing inpatient care, day care, outpatient care,
home care and education and training. Among people with AIDS, the
greatest fear is not fear of dying, but fear of dying alone. At our
hospice, no one dies alone. We are very proud of that.
But, Mr. Chairman, our hospice in South Africa has 8 beds, and the
nation has more than 4 million people infected with HIV. We are doing
everything we can with what we have, and we have comforted many people
and saved many lives. But we have done nearly enough. The people out on
the front lines fighting this disease need reinforcements, and they
need them now.
That means more funding for education and prevention; more funding
for voluntary testing and counseling, more funding for care of people
with AIDS, and more funding for orphans. And it emphatically means more
access to treatment. People with lives to lead, and work to do, and
children to raise must not be left to die just because they're poor.
Senator Helm's op-ed calling for anti-retroviral therapy to help
stop HIV-positive mothers from transmitting the virus to their babies
is an important first step. But we need to take the second step. We
need to treat the mother. If we don't treat her--who will take care of
her baby? What if that baby comes to sit here in the Senate 10 years
from now and says: ``Thank you for giving my mother the medicine that
helped saved my life, but why couldn't you give her the medicine that
would help save her life? Did you keep me alive just so I could bear
the agony of burying my mother?''
The drug companies are the only organizations in the world whose
resources can rival those of rich governments in battling this disease.
But, in my view, they have broken a public trust. They can't expect to
keep pulling in profits, have their research subsidized, and then go
missing in the midst of a world-wide health emergency. They can't keep
telling us they're in the business of saving lives, if they always put
business ahead of saving lives. We need them--and everyone--as
partners.
Mr. Chairman, it's late, but it is not too late. If we all step up
now with a full commitment to fight AIDS, they can still have a heroic
role in ending this epidemic. None have us have done all we could have
done or should have done in this fight.
Mr. Chairman, 95 percent of new infections come in poor countries.
They do not have the resources to defeat it. They desperately need your
help. No nation, corporation, foundation or individual has the money
you have. No one even comes close. This is the Government of the
richest Nation in history, and I'm here asking you for more money to
stop the worst epidemic in history. I am no student of government, but
I understand there are two ends to Pennsylvania Avenue, and this end
controls the money. The President can't sign what you don't pass.
If the world is going to make a significant, decisive intervention
to change the course of this pandemic, it's going to have to start
here. And it might as well start now. When Ryan White was asked by a
reporter if he had a message for medical researchers working on AIDS,
he said: ``Hurry up.'' We all need to hurry up. Every day we delay, we
lose more lives, and we lose a little more of our own humanity.
Mr. Chairman and members of the committee, we have one thing in
common, you and I. We have all been on stage and heard the cheers of
the crowd. In my line of work, if you really don't want it to end, you
can even keep it going for a few more encores--but soon enough the
lights go up, the crowd files out, and we all go home--and in that
silence we're left to ask ourselves whether what we do makes a
difference.
When our lives are done, won't we want it to be said that we saw
millions of people suffering with disease, millions more at risk,
millions more abandoned, a whole continent in danger of dying, and we
refused to let it happen. Mr. Chairman and members of the committee,
the United States Government is the biggest possible source of new
funding for fighting AIDS. Forty million people are infected with HIV.
Eight thousand people are dying every day. You have the power to end
this epidemic. Please end it.
It's true that one nation cannot defeat AIDS in 200 nations. But
200 nations cannot defeat AIDS without the help of one. This one. If
the United States does little, other nations will see in that an excuse
to do little. If the United States does a lot, other nations will do a
lot, because they will see in your resolve a new hope of victory. When
the United States fights, it wins.
Mr. Chairman: what America has done for its people has made America
strong. What America has done for others has made America great. I pray
that defeating AIDS will be one more great victory.
Thank you very much.
The Chairman. Thank you very much for a very eloquent and
compelling statement. It is certainly a challenge, not only to
the members of our committee here, but to the institution and
to the American people.
We are very grateful to you for it.
We will next hear from Dr. Peter Mugyenyi who, since 1992,
has been executive director of the Joint Clinical Research
Center in Kampala, Uganda and played a major role in the
successful Uganda AIDS Control Program. Dr. Mugyenyi is
currently chair of the Uganda Health Science Committee.
Uganda has been one of the most successful countries in
Africa in reducing HIV and AIDS, and this very special
individual has done a very extraordinary job in seeing that
that has been achieved.
We welcome you here, Doctor, and we look forward to hearing
from you. Thank you very much.
STATEMENT OF PETER MUGYENYI, M.D., DIRECTOR, JOINT CLINICAL
RESEARCH CENTER, KAMPALA, UGANDA
Dr. Mugyenyi. Thank you, Senator Kennedy. Thank you for
inviting me here. I see some familiar faces. I thank Senator
Frist and Senator Clinton.
I testify as a physician who is working in AIDS and who has
been involved for over 10 years, and every day of my life I see
an AIDS patient as long as I am in my country, Uganda.
I would like to give you some background to what is
happening on our continent, because AIDS has devastated the
continent of Africa. It has killed the youth in their prime and
most productive age, and it has done this at the time when
their families most need them.
It has diminished skilled manpower in banks, in industries
and institutions, and it has reversed hard-won advances that
Africa was making. In fact, as has already been said, it is a
significant political and destabilizing force on our continent.
Just to give you a few examples, in Zambia, the country is
losing teachers due to AIDS faster than they can train teachers
to replace them. Every year, the capacity to train children in
that country diminishes. A few years ago, it was estimated that
South Africa would lose the economic advantage it had; growth
would be down annually by 0.4 percent, GDP by 17 percent, and
$20 million of the existing economy would be wiped out, let
alone development itself.
The situation has gotten worse since these estimates were
made, and the situation is becoming grimmer. As you are aware,
Africa is the home of AIDS. Over 70 percent of AIDS patients
are found in Africa, and it is the leading cause of morbidity
and mortality.
I would like to take this opportunity to give you an
example of my country, Uganda, which had the highest prevalence
of AIDS in the world, but our government took strong measures
through openness, public information, and the AIDS level has
been reduced from a high of over 30 percent to the current rate
of 6.2 percent.
As good as this might look, it is still unacceptably high
and appalling. Yet this is one of the most hopeful scenarios in
Africa which needs to be emulated. But the situation elsewhere
is much grimmer, and nowhere is it grimmer than in southern
Africa itself.
I would like to take you to a small country called
Botswana, with a population of over one million, where in some
sentinel sites, over 50 percent of women attending antenatal
clinics are HIV-positive. Without treatment, 30 percent of
these infected women will give birth to infected children.
I would like to talk a little bit more to explain what this
means. These infected children will be so sick that they will
add to the strain of the medical sector. The mothers
themselves--these 50 percent that I talked about--will die
without treatment. When they die, they will leave orphans, not
to mention the socioeconomic strain on the country and lessened
capacity to educate these orphans.
The health facilities in Africa are devastated. AIDS now is
the biggest occupier of hospital beds in Africa. But AIDS is a
secondary epidemic. These secondary epidemics of tuberculosis
have now become a worldwide scourge and are killing most AIDS
patients. There are other life-torturing diseases like
cryptococcol meningitis, which causes excruciating headaches,
tortures patients, and sends them into a coma before it kills
them, inevitably, without treatment. That can be repeated for
toxoplasmosis, that can be repeated for many other diseases,
especially cytomegavirus, which makes them blind, they live for
some time, they are totally helpless, and then they die. This
is what we live with every day in Africa.
Now, there is overwhelming evidence that prevention works.
Uganda has demonstrated that prevention works. However, it is
abundantly clear that prevention cannot work without treatment;
it just works partway, but not well enough to make an impact on
this very devastating epidemic.
The main constraint we have in Africa is the high cost of
the drugs. We are tackling, with our colleagues, especially
from America, scientific issues that might help to deal with
these scientific issues, which we now think are not a
constraint to the use of antiretrovirals in Africa.
My center, the Joint Clinical Research Center, has had a
highly successful program of AIDS treatment using
antiretroviral drugs. We did this without any help from any
other country, but we could only do it in a very limited way.
Our objective was to demonstrate that it works, and we have
abundantly demonstrated that AIDS treatment works and works
very well in Africa. Lives are saved in Africa when we use AIDS
treatment.
Now, the way forward. Africa needs the United States.
Africa needs you to help us to come to grips with this problem.
Currently, drugs are in very, very few places, yet the
disease is in Africa. Drugs are where the diseases are not. The
drugs should be in Africa. That is where the diseases are, and
we need your help to get the drugs there.
AIDS is a catastrophic tragedy, and arguably, surpasses all
disasters of the centuries gone by. Yet this is very
important--AIDS is actually one of those disasters that can be
controlled. There are well-proven methods of controlling it,
and there is treatment that is effective and available. We need
help to make sure this treatment reaches us, and we look up to
you to come to our aid, and when you do, we in Africa will play
our role to make sure that this partnership is a winner, not
only for Africa, but for the entire developing world, and
indeed, the world itself.
Thank you.
[The prepared statement of Dr. Mugyenyi follows:]
Prepared Statement of Peter Mugyenyi, M.D.
impact
HIV/AIDS has devastated the continent of Africa, killing the youth
at their prime and most productive age, when their families and
countries most need them, diminished skilled manpower in key industries
and institutions and is reversing the hard worn advances in health,
social-economic, and cultural development.
In Zambia, the country is losing teachers due to AIDS faster than
they can train replacements. Every year, the country's capacity to
educate the children for a better future diminishes. A few years ago,
economists estimated that AIDS in South Africa will slow down the
economic growth by 0.4 percent annually, cut GDP by 17 percent, and
wipe out $22 million of the existing economy by the year 2010. The
situation has since gotten worse and estimates are being revised
upwards. Africa is home to over 70 percent of the world's population of
over 36 million people living with AIDS, and is the leading cause of
morbidity and mortality.
the scope of the problem
In early 1990s, Uganda had the highest prevalence of HIV/AIDS in
the world, but the government implemented strong preventive measures
through a policy of openness, public information, communication and
education, and national and international collaboration through
patternship of private and public sectors to bring down HIV/AIDS rate
from the high level of over 30 percent in some antenatal sentinel sites
to the current level of 6.2 percent. However, this rate remains
unacceptably and appallingly high. Yet this is one of the most hopeful
scenarios in Africa and an example to emulate. For the most of the
continent the situation is much grimmer! Currently, the highest rates
are in Southern Africa where the epidemic is causing unimaginable
suffering, especially to the poorest sector of society. In some
sentinel sites in Botswana, a shocking prevalence of over 50 percent of
women attending antenatal clinics are HIV positive. Without treatment,
over 30 percent of these infected women will give birth to infected
children. These infected children will be so sick that they will add to
the strain on the already over-stretched health sector. The mothers
themselves will die, leaving a generation of orphans without parental
guidance, not to mention the social and economic strain on the country
and individuals concerned with lessened capacity for education and life
achievements. The health facilities are already overwhelmed by the
adult infected cases of AIDS who already occupy the vast majority of
hospital beds with very serious opportunistic infections. Secondary
epidemics of opportunistic infections have emerged and include
Tuberculosis that kills most AIDS patients, Crypotoccocol Meningitis
that tortures patients with excruciating headaches that progresses to
mental confusion, coma and inevitable death if not treated,
toxoplasmosis that causes terrible convulsions and eventual death, and
Cytomegavirus infection that causes blindness and helplessness, and
many other infections that could all be largely prevented, or at least
ameliorated, by a program of treatment.
The devastation and AIDS trend all over Sub-Saharan Africa is
upward. The epidemic is totally out of control, the continent's
economies increasingly unable to cope with the demand and scarce
resources are diverted from other developmental programs in vain.
There is overwhelming evidence that strong preventive measures
implemented will have a big effect in control of the epidemic. However,
it is abundantly clear that without treatment the AIDS epidemic would
not be effectively controlled in the developing countries. The main
constraint to treatment is the high cost of the AIDS drugs
(antiretrovirals) which are beyond the economic means of most
developing countries. The lack of adequate infrastructure and trained
manpower is also a constraint that need to be addressed, but is not a
major handicap to widespread use of Antiretroviral (ARV) drugs in
Africa. The Joint Clinical Research Center (JCRC) in Uganda has
implemented a highly successful program of AIDS treatment using ARV
drugs just as they are used in the United States. The center has gone
further to carry out operational research that would inform the way
forward for countrywide good practice in ARV drugs use. Of particular
importance are low cost, user friendly and sustainable laboratory
diagnostic and monitoring tests. JCRC is now working with American
scientists to identify simplified and cost effective ARV treatment
regimen that may be adopted for wider use in Africa. Pilot projects in
Uganda now also being implemented in some parts of Africa have
demonstrated that AIDS treatment is feasible, desperately needed, and
has the potential to impact on the epidemic control. Each country in
Africa given the necessary resources can implement a successful
preventive program, and start AIDS treatment, which can in a stepwise
methodology be extendable to the communities. A nationwide referral
system of specimens and patients may be one of the practical ways
forward as infrastructure develops. An outline of such a program is
outlined in the power point slides and can easily be adopted for
implementation by all countries.
way forward
It needs to be recognized that Africa, and indeed the entire
developing world, is in urgent need of help to treat millions of people
suffering the now mainly treatable AIDS. Currently, the drugs are not
available where they are needed desperately, yet AIDS is the most
catastrophic tragedy of humanity today, arguably surpassing all the
disasters of the last century put together! Yet there are few disasters
that can be so effectively controlled by well proven methods of
prevention, care and treatment. Aid for AIDS should not be equated with
the ``unsolvable'' vast problems of the developing world, but rather as
part and parcel of the solution to such issues by investing in the
human capacity of the people of Africa.
expected outcome
With appropriate help AIDS can be controlled and moved from a
devastating epidemic to a controllable sub-endemic disease. Many lives
would be saved and the suffering would be minimized. It would make a
saving in economic terms that would be injected into the economies to
improve social services and relieve the strain on medical facilities.
It would free the infrastructure to deal with the endemic tropical
diseases that are also rampant, but only overshadowed by the
devastation of AIDS. The governments would be under less pressure from
their populations to concentrate on issues of family and development.
The interventions are urgent because every year millions are added on.
conclusion
There is great demand for AIDS drugs in developing countries. Huge
numbers of desperate people staring death in the face know very well
that life saving treatment exists. If they get hold of any drugs,
whether fake, generic, bland, under dose or toxic, they will take their
chance on it. This is a fertile ground for black-marketeering and for
unqualified dealers to step in with disastrous long term implications.
Governments and international donors must not let this situation
develop further, and need to work together to avert this super-
catastrophe, by facilitating an effective program against AIDS.
The Chairman. Thank you very much, Doctor. You have
demonstrated what can be done and give us a great sense of
hope, that if we give the support and resources, it can make a
very important difference, and you have demonstrated that.
Dr. Allan Rosenfield is currently dean of the Mailman's
School of Public Health at Columbia University. He is currently
chairman of the New York State Department of Health AIDS
Advisory Council and chairman of AMFAR's Public Policy
Committee. He has worked abroad, as well as domestically, on
family planning and maternal and child health issues. He has
pages of international awards, degrees, and achievements.
We are very, very glad to have you here, Doctor. We are
thankful for all of your good work in the past and look forward
to your testimony.
STATEMENT OF ALLAN ROSENFIELD, M.D.,DEAN, SCHOOL OF PUBLIC
HEALTH, COLUMBIA UNIVERSITY; DIRECTOR, MTCT-PLUS INITIATIVE,
NEW YORK, NY
Dr. Rosenfield. Thank you very much, Mr. Chairman and
distinguished members of the committee. Thank you for inviting
me to testify and, more importantly, thank you for holding this
committee hearing.
I thank my previous panelists, particularly Sir Elton John,
for the eloquent presentations that have already been made.
I am an obstetrician/gynecologist by training, so the
impact on women and children is particularly touching and
moving and important to me as a professional.
I would like to use my time to discuss one of the issues
that I think is of key importance and an approach to beginning
to introduce more effectively treatment in poor countries.
Mothers and children are suffering the heaviest toll from
the AIDS epidemic. More than half the global toll of AIDS
involves women and children. In one year, more than 1.5 million
women die from AIDS while another 2.5 million become infected.
According to UNAIDS estimates for 2001 alone, approximately 2.6
million pregnant women had HIV infection, and more than half-a-
million transmitted the virus to their infants.
To put this in perspective, as I think was mentioned
earlier, more than 1,500 children become infected each day.
Over the last few years, groundbreaking progress has been
made in the prevention of maternal, mother-to-child
transmission, called MTCT programs, using a well-established
package of low-cost and effective practices including single
doses of an antiretroviral drug, nevirapine, for both the
mother and the baby.
The Elizabeth Glaser Pediatric AIDS Foundation, UNICEF,
Medicins Sans Frontiers, USAID, CDC, and many others are
leading this global effort to expand these programs, and there
are currently estimated to be more than 200 MTCT prevention
sites in more than 20 countries, but we need much, much more.
While MTCT programs to prevent mother-to-child transmission
are a tremendous step forward, these programs do not--and I
repeat, do not--provide treatment to the mothers themselves.
The mothers simply deliver the drug to the babies.
The tragedy is that the babies that we save through the
MTCT programs are likely to be motherless by the time they can
walk. Affording to studies in Africa, children whose mothers
have died are three to four times more likely to die
themselves--three to four times more likely to die--if they are
orphaned.
I believe we face a social and moral imperative to now add
treatment of the mothers and their infected children. Survival
of mothers will not only benefit the mothers, but will secure a
brighter future for the children and will create optimism that
can only further enhance prevention efforts.
When the Elizabeth Glaser Foundation called their sites
where the MTCT programs are currently underway, there was
uniform and unanimous and enthusiastic support for expanding
those programs to provide treatment for the mother, her
children, and her partner.
This is a unique moment in the history of the AIDS
pandemic. We have an important opportunity to extend care and
treatment to mothers and their families given the rapidly
increasing possibility of providing treatment in poor areas,
reduction in drug prices--and we need to work on that--the
recognition that treatment is essential and complementary to
effective prevention programs.
The international foundation community has responded to
this challenge by responding to a major new initiative called
MTCT-Plus. This program will add care and treatment of HIV-
infected mothers and their families to existing MTCT prevention
programs. This is a concrete example of how prevention and care
can come together. The new initiative under my leadership and
based on Columbia University's Mailman School of Public Health
is currently supported by a partnership of nine foundations
which are listed in the testimony, and is part of the
foundation community's response to Kofi Annan's call to action
on HIV/AIDS. These include Gates, Hewlett, Johnson, Kaiser,
MacArthur, Packard, Rockefeller, Star, and United Nations
foundations in a unique and unusual collaboration on the part
of these foundations to pool their resources to try to work
with the Global Fund in moving this forward.
Our goal is to raise $100 million through the private
sector, and we hope that we will be able to include Federal
support for this program, perhaps matching that goal before we
are finished.
We are building a strong partnership between this program
and the Global Fund for AIDS, Tuberculosis and Malaria; and in
fact, as some of you know, we will be hosting the next Global
Fund board meeting at Columbia University 10 days from today.
What is the aim of the MTCT-Plus initiative? This
initiative aims to demonstrate that HIV treatment can be
delivered effectively and efficiently in resource-poor
countries. It will serve to develop a model that can be
replicated by others around the world. We will be working
closely with the UN family of agencies, Federal agencies, and
nongovernmental organizations on the design and implementation
of MTCT-Plus to ensure effective coordination on a regional and
global level.
Ladies and gentlemen, committee members, for the pregnant
woman with HIV infection today, the future is one of despair.
She is offered one hope--the hope for a baby without HIV who
will have to survive without her.
In contrast, what we hope that MTCT-Plus will provide for
this woman is a chance for her to survive, for her to be able
to raise her own children, sustain her family, and contribute
to her community.
We urge you to allocate resources to join this private
initiative as a public-private partnership, matching the
private foundation funding, to expand this effort, and to make
HIV care and treatment available to the women and families who
desperately need our help.
I think that Sir Elton put it so eloquently: This
Government and this country has a unique opportunity to do
more. Now is the time to do more. The pandemic is not slowing
the way it should. We need help from this committee and from
our Congress and from our country.
We believe that with your leadership, resources, and the
will to succeed, MTCT-Plus and all the other care initiative
that will follow can save the lives of thousands now and create
lasting hope for millions in the future.
Again, thank you for allowing me to testify, and thank you
for the work that you are doing.
[The prepared statement of Dr. Rosenfield follows:]
Prepared Statement of Allan Rosenfield, M.D.
Mr. Chairman and distinguished members of the committee, thank you
for inviting me to testify this morning. The global HIV/AIDS pandemic
is clearly the most urgent health threat of our time, and your
leadership and determination is very much appreciated.
I am Dr. Allan Rosenfield, Dean of Columbia University's Mailman
School of Public Health and DeLamar Professor of Public Health. I am an
obstetrician/gynecologist by training and have dedicated my
professional career to maternal and child health, both domestically and
internationally. I currently chair the New York State Department of
Health AIDS Advisory Council and the Public Policy Committee of the
American Foundation for AIDS Research. Before joining the faculty at
Columbia, I spent 7 years in the developing world--in Nigeria at the
University of Lagos Teaching Hospital and in Thailand as Medical
Advisor to the Ministry of Public Health.
We have heard moving testimony this morning about the scope of the
AIDS tragedy, particularly the devastating impact on children and
families. I would like to use my time to discuss one of the solutions--
a new multi-foundation program to link prevention with care and
treatment for HIV-infected women and their families in the poorest
countries.
a program to build on
Mothers and children are suffering the heaviest toll from the AIDS
epidemic. More than 1.5 million women die each year from AIDS, while
another 2.5 million become infected. According to UNAIDS estimates for
2001 alone, more than 2.6 million pregnant women carried HIV, and more
than half-a-million transmitted the virus to their infants. To put this
in perspective, more than 1,500 children become infected each day.
Over the last few years, groundbreaking progress has been made in
the prevention of mother-to-child transmission (MTCT) of the virus
using a well-established package of low-cost and effective practices,
including single doses of the antiretroviral drug Nevirapine for the
mother and baby. Nevirapine has been shown to cut transmission of the
virus nearly in half and costs only $4 for the mother and child. In
many cases, Nevirapine has been provided free of charge by the
manufacturer. The Elizabeth Glaser Pediatric AIDS Foundation, UNICEF,
Medicins Sans Frontieres, the CDC and others, are leading a global
effort to expand MTCT programs, and there are now approximately 180
MTCT sites in more than 20 countries.
While programs to prevent mother-to-child transmission are a
tremendous step forward, the tragedy is that the children we save are
likely to be motherless by the time they can walk. These orphans face a
life of poverty, malnutrition, and a host of social ills. According to
studies in Africa, children whose mothers have died are three to four
times more likely to die themselves. In the current MTCT programs, the
mothers are offered no hope for their own survival, and without the
prospect of treatment for themselves, they have less of an incentive to
seek testing and participate in prevention programs in the first place.
I believe we face a social and moral imperative to treat the mothers.
towards an mtct-plus program
We have an important opportunity to extend care and treatment to
mothers, given the rapidly increasing possibility of antiretroviral
treatment in poor areas, drastic reductions in drug prices, and the
recognition that treatment is essential to effective prevention. The
critical need to go beyond prevention was clearly recognized by the UN
Special Session on AIDS last summer in the Declaration of Commitment
and by health advocates, international organizations and governments
worldwide.
The international foundation community is responding to this
challenge by committing to a major new initiative called MTCT-Plus.
MTCT-Plus will add care and treatment of HIV-infected mothers and
families to existing MTCT prevention programs, in a concrete example of
how prevention and care can come together. The new initiative, under my
leadership and based at Columbia University's Mailman School of Public
Health, is currently supported by a partnership of nine foundations \1\
and is part of the foundation community's response to Kofi Annan's Call
to Action on HIV/AIDS. We are well on our way towards meeting our
private foundation fundraising target of $100 million over 5 years.
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\1\ Bill and Melinda Gates, William and Flora Hewlett, Robert Wood
Johnson, Henry J. Kaiser Family, John D. and Catherine T. MacArthur,
David and Lucille Packard, Rockefeller, Starr, and the United Nations
foundations.
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We are also building a strong partnership between MTCT-Plus and the
Global Fund for AIDS, Tuberculosis and Malaria and will host the next
Global Fund Board meeting at Columbia later this month. Our aim is to
demonstrate to the Global Fund and others in the international health
community that treatment can be delivered effectively in resource-poor
countries. In addition, we are working closely with UNAIDS and WHO on
the design and implementation of MTCT-Plus to ensure effective
coordination on a regional and global level. Finally, we see tremendous
opportunities for partnerships with bilateral assistance agencies and
are already consulting closely with CDC, NIH, and USAID.
The MTCT-Plus initiative will select existing MTCT prevention
programs and add the ``Plus'' component, which includes HIV/AIDS care,
treatment and support services for infected women and families. The
package of services will include education, counseling, nutritional
support, diagnostic testing, prophylaxis and treatment of selected
opportunistic infections, like tuberculosis, and anti-retroviral
therapy. Patient treatment will be guided by standardized clinical
protocols that were developed by an international group of experts. The
treatment guidelines will be flexible and will evolve as newer drugs
and tests become available and as more is learned about HIV care in
resource-poor settings.
The MTCT-Plus care team will be multidisciplinary, and psychosocial
support, patient education, and counseling will be available at each
visit. Patients will be encouraged to choose from a menu of supportive
services, tailored to local circumstances and the needs of affected
families. While the focus of the program is on pregnant women and their
children, sites will have the opportunity to design a family-centered
program, enrolling husbands and other household members. MTCT-Plus will
also support community outreach and education, and work to build
linkages to local organizations and resources.
the first stage
The first stage of the program will be to select 10-20 existing
MTCT programs to serve as demonstration sites. To be eligible, these
sites must be located in resource-poor areas where the HIV prevalence
among women is greater than 5 percent; we anticipate that the majority
will be in Sub-Saharan Africa. Sites must demonstrate their ability to
provide MTCT prevention services, including voluntary testing and
counseling, standard obstetric, gynecologic, maternal and pediatric
care, and reproductive health and nutritional services. The sites must
have the capability to expand their services to provide HIV care to
infected women and their children. We are also requiring a
demonstration of local community and government support.
Selected sites will be given approximately $200,000 per year for
personnel, training, laboratory costs, operational support, and minor
infrastructure needs. In addition, we will provide technical
assistance, any additional training required, oversight, and drugs
including antiretroviral therapy. In some case, we will provide
planning grants of up to $15,000 for the development of future
applications.
Earlier this year, we initiated a rigorous application process to
select our first group of demonstration sites, and we have identified a
panel of independent experts to review the applications. Application
requirements include detailed descriptions of existing health services,
proposed strategies for providing HIV/AIDS care and treatment within
one year, and detailed budget proposals. More than 70 MTCT sites have
already indicated their intention to apply, and we expect to announce
the first sites by June and begin operation by the fall. We plan to
select the second group of sites in late 2002.
At current funding levels, however, we only expect to be able to
enroll between 25,000 and 50,000 HIV-positive women, children, and
family members over the lifetime of the program. A major financial
commitment is needed to expand this program to the hundreds of
thousands, if not millions, of affected families.
a model for the future
The MTCT-Plus program provides a path towards bringing HIV care to
women and their children. Delivering care and treatment to infected
women and their families will prolong their survival--and their
children's survival--and improve their well being. It can decrease the
stigma associated with HIV and, with the hope offered by treatment, it
can strengthen prevention programs. However, the foundation community
cannot do this alone. Therefore, we urge the Congress to join us in a
public-private partnership to expand this effort and begin making care
and treatment available to the women and families who so desperately
need our help. We believe that with strong leadership, sufficient
resources, and the will to succeed, we can save the lives of thousands
now--and create lasting hope for millions in the future. If we work
together, we can make a difference.
The Chairman. Thank you very much, Dr. Rosenfield.
Senator Frist, would you like to introduce Ms. Dortzbach?
Senator Frist. Yes. Thank you, Mr. Chairman.
I have the pleasure of introducing our final witness today
before we go to our discussion period. Ms. Deborah Dortzbach is
currently the international director of HIV/AIDS programs with
World Relief International in Nairobi, Kenya. Her extensive
work in the HIV/AIDS field spans both the United States as well
as Africa.
Abroad, Ms. Dortzbach has provided direct medical relief as
a nurse in Ethiopia, Eritrea, and Kenya. She has also been
program director of health training programs and HIV/AIDS
support programs with Mission to the World and MAP
International.
Ms. Dortzbach, thank you for being with us this morning.
STATEMENT OF DEBORAH A. DORTZBACH, INTERNATIONAL DIRECTOR, HIV/
AIDS PROGRAM, WORLD RELIEF INTERNATIONAL, BALTIMORE, MD
Ms. Dortzbach. Thank you.
This is not an easy position to be in, last on this panel.
But I do look forward to a thunderous encore to this issue that
we are addressing today, together. And we will applaud you, our
Senators--the world will applaud you--for your energy and
enthusiasm and action to what we are presenting to you today.
I have brought someone with me, but you will not see her.
Please do listen to what she has to say.
[Remarks of Elizabeth via audiotape:]
My name is Elizabeth, and I am 11 years old. I live in
Kenya with my mother and two brothers. My father died
of AIDS 2 years ago. My mom has AIDS. After my father
died, relatives came and took all of our family
property. Now we struggle to get money for school fees.
I do not know what will happen in the future. If my
father were alive, I would be the happiest girl in the
whole world.
Ms. Dortzbach. Elizabeth's story is not over. She will
still face the death of her mother, the stigma which Sir Elton
John referred to of her neighbors and her friends, and she will
probably not finish school.
The question we have is what can we do to make an ending
that is different for Elizabeth and the millions like her.
Africa has been my home for 22 years. As an American, I was
extremely vulnerable one day when a band of rebels entered the
hospital where I was working and took me hostage for 26 days.
You know the end of my story--I am here with you today, and
I am grateful that I was released and could return to Africa.
There, I was hopeful in the 1970s and the 1980s, when we helped
children survive to the age of 5. But in the 1990s, we buried
them as young people.
I am with World Relief, located right here in Baltimore at
our headquarters. We work for about 45 different denominations
and all different religious and faith-based groups throughout
the world, in 24 countries, and we have been around since 1944.
I would like to suggest a few opportunities that the band
of nongovernmental organizations, many of whom are here today,
can contribute to the challenge before us in this crisis.
We call our HIV/AIDS program Mobilizing for Life, and we
work through the family, the basic unit that we are given, to
nurture and to care and support and provide for our orphans,
extended as well as nuclear.
In Mozambique, there is a group of 50 churches that have
shed their different denominational perspectives and are coming
together to care, in homes, for 352 orphans.
The faith community is here to stay, beyond our funding
cycles and after we leave our rusty four-by-fours. In Kenya, a
group called Faraja, which means ``comfort'' in Swahili, is a
simple group of men and women. Their only badge is this little
piece of metal, but they are recognized in their community as
people who bring comfort. It does not cost anything, but what
they give us is priceless.
This did cost something. This small manual, ``Hope at
Home,'' is simple enough that even children can understand it
and use it, because like it or not, they are the primary
caregivers of their dying parents.
I am proud to say that my Government, through USAID, funded
this project, and we need more. Financial strengthening is
another area of interest for World Relief. We have credit and
savings in small loans with more than 73,000 clients worldwide
in 10 different countries. Ninety percent of them are women.
They do not default on their loans; they have a loan loss rate
of less than 2 percent. But what it does give them is a
stronger economic base and the financial strength so that they
have better options and choices to prevent AIDS from entering
their families and affecting their children.
We cannot do this alone--none of us can. That is why we are
here today. That is why we plead with you. We need people; we
need training; we need networking; we need each other. Only by
working together can we make a difference in this crisis.
I am grateful that our organization has partnered with
many, including Freedom from Hunger, based in California, and
their phenomenal track record in microenterprise development in
health education. Together, we have developed a curriculum that
is used worldwide in helping community banks understand more
about HIV/AIDS.
But it is not just organizations. It is individuals who
make the difference. In New York City, I worked with Anna,
Jerome, Maribel, Raquel, all of them nurses who wanted to get
involved and even come to Kenya and help out in some small way.
There are children in Fredericksburg, VA who are helping to
make small bed pads for people in Africa who have problems with
bedsores.
I was powerless while being held hostage by terrorists,
taken because I was an American. But today, I am strengthened
because I am an American. And I know that my country has power,
influence, and money to change the course of millions of
Elizabeths, their mothers, their dads, their families. We
cannot bring back Elizabeth's dad, but we can raise her and
love her and help her live until she reaches her 70s.
Join us in the NGO grassroots assault on the terror and
tragedy of AIDS.
[The prepared statement of Ms. Dortzbach follows:]
Prepared Statement of Deborah A. Dortzbach
Mr. Chairman and members of the committee, thank you very much for
the opportunity to appear before this subcommittee. I am Debbie
Dortzbach, International Director for HIV/AIDS for World Relief located
in Baltimore, Maryland. We are a worldwide organization committed to
alleviating suffering in the developing world.
I am here today to represent the non-government agencies and to
address how we can contribute to curbing HIV/AIDS and caring for those
affected.
i. elizabeth's story
You haven't met her, but you know her.
She is one among millions you have talked about in these rooms. It
is our time now to listen to her.
My name is Elizabeth, and I am 11 years old. I live in Kenya
with my mother and two brothers. My father died of AIDS 2 years
ago. My mother also has AIDS.
When my father died, my uncles came and took all our property.
Now it is difficult to get money for school fees.
If my father were alive, I would be the happiest girl in the
whole world.
Elizabeth's story is not over. She will face the death of her
mother, confusion over what to tell people who scorn AIDS as a curse
from generation to generation, the reality of stigma and rejection, the
loss of household income, the threat of having to stop school, and the
reality of not having an evening meal or the next morning's breakfast.
By 2010 we will have 41.6 million double orphans, those who have
lost both mother and father (Children on the Brink, USAID Report by
Susan Hunter and John Williamson, 2000).
As I think of Elizabeth, I am burdened by the question, ``What role
can we have in giving Elizabeth's story an ending of hope?''
Africa is also my home, now for more than 22 years. I am an
American, and because I am, I was targeted in a 1974 hostage raid on a
church hospital in northern Ethiopia, now Eritrea. After 26 days I was
released to my husband and 4 months later gave birth to our son.
We returned to Africa, invited to join the vigorous efforts of
hundreds of thousands of ambitious and determined Africans in advancing
their cultures and countries and participating in their health and
development initiatives. I expected years later to leave Africa a
changed place: with healthier children, more educated families, men and
women honoring each other, and families strengthened with a brighter
economic future.
It is more likely that in next 10 years before we retire that many
markets and streets will be flooded with orphans, families impoverished
for generations, schools barren of teachers, and roads impassable for
lack of skilled workers and money to repair them.
In the 1970s and 1980s, we helped children survive to the age of 5.
In the 1990s, we buried them as young adults.
As a former hostage, I often wonder why God spared me. Why did I
come home? There were two of us taken and Anna was shot, by our
captors, in my presence.
Today, I still ask that question, but I know just a bit more of the
answer.
We have a job to do.
ii. the challenges and contributions of ngos
Today, I am addressing you as a member of the family of World
Relief, a Christian NGO representing more than 49 different
denominations in the United States and working in over 24 countries
since 1944.
Our challenge is to apply foundations of sound knowledge about what
works in AIDS, cultural strengths, spiritual commitments, and decades
of public health and behavior change experience.
We know these foundations build success. We need focus to
strengthen them. In World Relief we call our HIV/AIDS program,
``Mobilizing for Life,'' and our focus can be summarized around three
themes: the family, the faith community, and financial strengthening.
A. The Family
The basic social foundation is the family. To a very large extent,
what happens within the family determines the global course of this
epidemic. Strengthening communication, education, and cross-
generational dialog within the family is one of the goals of a USAID-
funded project known as Amkeni, in which we are partners in Kenya.
The project works through churches and other community groups to
foster understanding and equip families to reflect on behavior and
promote relational and sexual health. Choose Life: Helping Youth Make
Wise Choices is one tool with many lives. Originally developed through
a USAID Rwanda project, (USAID/Rwanda/HARR Award No. 623-A-00-99-00071-
00), the manual is adapted and currently in use in training in Kenya.
The family is also the primary institution for care of orphans and
other vulnerable family members such as the elderly. Though taxed
beyond coping ability in some cases, the majority of extended family
members and the community surrounding them are the best homes for
children whose parents have died. Every community institution can
support the family, keeping children at home where they belong.
Kubatsirana, a Mozambiquan organization of faith communities in Chimoio
representing over 50 churches is an example of communities working
together to assist over 352 orphans. Every orphan is known, every
village elder oversees their welfare, every church takes on the
responsibility of visiting and supervising care regularly, and every
school and many businesses in the community assist in meeting basic
needs.
B. The Faith Community
In nearly every community in Africa people meet to express their
faith. Faith communities are institutions here to stay, beyond our
funding cycles and rusted 4x4s. What we build today on the foundation
of faith is cost-effective, integrated into life and relationships, and
spans generations.
Faraja, meaning comfort in Kiswahili, is a community of people of
faith from many backgrounds drawn together out of concern for caring
for people with AIDS at home in an urban poor community in Nairobi.
Members of Faraja dedicate themselves to weekly learning sessions on
how to train family members to care for their HIV-positive members. The
training occupies no line-item in a budget and does not take place in
an expensive hotel, but sitting on wooden benches in a tin-roofed
church buried in the sprawling slums. The learners bring their passion
and time and commit to working in teams, regularly visiting all sick
living near them. What they learn costs nothing to do and can be
universally applied and life-changing: the importance of touch and
embrace, acceptance and inclusion of persons living with HIV/AIDS
(PLHA), the need for PLHAs to stay active in the family and society,
the control of TB, preparation for death and the care of orphans left
behind. Faraja members use a simple home care manual, ``Hope at Home.''
It has photographs and simple, short sentences so even children--who
are often the primary caretakers of their parents--can understand and
safely assist. Local government clinics and an area hospital provide
HIV testing for family members, clinical support and backup for
critically ill patients. Faraja caregiver trainers are recognized by
the red badge they wear, ``Wahumu wa Faraja''--people bringing comfort.
In Rwanda, faith communities send their leaders to workshops to
apply community advocacy roles, learn principles of counseling in
trauma healing, destigmatize AIDS and the misbelief that AIDS is a
curse from God, learn the facts about HIV/AIDS, and use training tools
to help youth make wise choices about their sexuality. As a result,
more than 160 support groups of persons living with AIDS meet weekly in
churches for support. Churches are developing their own integrated
programs for AIDS interventions in care and prevention, including
counseling, training, care, and food distribution.
In Malawi, churches band together in committees to determine how to
help the families affected by AIDS living around them. They work
community gardens where volunteers cultivate, fertilize, plant, water,
weed, and harvest food for orphans.
The church is an advocate for those too weak to speak. In
Mozambique, church leaders take village chiefs around their communities
to identify orphaned children. More than 352 children in Chimoio are
guaranteed the right to free primary education and businessmen and
women contribute food and other necessary household items to the
orphans.
C. Financial Strengthening
World Relief enables individuals and families affected by HIV/AIDS
to live with dignity by addressing the economic burden of HIV/AIDS
through micro-enterprise development programs. Economic development
opportunities give poor women, who are among the most vulnerable,
better means to make healthy choices about sexuality.
Credit and savings enable families to appropriately address the
medical needs of their members with AIDS, continue to nurture children
left behind by the death of their parents, and remain engaged with
their communities. HIV/AIDS-affected families who participate in micro-
enterprise programs continue to earn income, maintain social support,
and make wise decisions about treatment options. Micro-enterprise
activities also help prevent new infections. Women, who are empowered
socially and economically through their micro-enterprises, gain more
control of their lives.
World Relief assists in the administration and supervision of
microfinance institutions in 10 countries including Rwanda, Mozambique,
Burkina Faso, Haiti, and Cambodia, with a loan portfolio of 5.8 USD.
These institutions serve 73,000 clients, nearly 90 percent of whom are
women, with a loan loss rate of less than 2 percent. Most of these
women move on to larger loan cycles and savings schemes.
In partnership with another non-government agency, Freedom from
Hunger, we developed an interactive prevention and care curriculum,
``Facing HIV/AIDS Together,'' being used in communities where clients
meet regularly as a group to repay their loans (Publication made
possible through the G/PHN/HN Grant Award #HNR-A-00-07-00007-00).
In addition to providing basic education on cause and prevention,
the curriculum encourages communication within families, mobilizes
these groups for community action and helps break down stigma.
Rose Mukamguguje, an HIV-positive Rwandan widow, struggled to feed
and educate her children after her husband died. She was forced to pull
her six children out of school because she couldn't afford the fees and
was concerned about what would happen to them when she died. Before she
received a loan to start her own business, Rose was engaged in the
back-breaking work of hauling construction materials. In her words: ``I
used to get temporary jobs fetching water or bricks at a construction
site, but this was very difficult for me. The next morning I would be
broken. I would be very weak and stay in bed. I got sick more often
during this time.''
But through this bleak reality glows light--the light of people of
faith practicing what they believe in nearly every community in
Africa--far from medical outposts, medical professionals, corner
pharmacies, means of transportation other than footing, and
communication.
iii. implementing prevention and care
A. People
In America, we think of hospitals, doctors, and medications when we
think of treating AIDS. In reality, we will never have enough
accessible hospitals and doctors to meet the demand, and we need to be
realistic about the availability of medications over the long haul in
most rural communities and urban poor centers where daily earnings are
less than the cheapest American hamburger.
But we have people living in community. They are neighbors,
teachers, nurses, pastors, and youth. They are the greatest community
resource, not yet fully marshaled or supported.
In Malawi, youth groups meet the challenge of helping families with
AIDS by hauling jerry cans of water, repairing roofs, tilling gardens.
They learn not only how to give community service, but come face to
face with the reality of people dying with AIDS--a powerful incentive
for delaying sexual activity.
Through working within community structures, equipping, and
continued support and encouragement we can meet the most basic needs
for not some, but most people living and dying with AIDS and their
millions of orphans.
World Relief's orphan initiative begins with families, communities,
and churches. Rather than a project, it is described as a ``movement''
known as ``Every Church, Every Orphan'' seeking to marshal support from
every church in every community where there is one to take a census of
every orphan in a perimeter around the church and provide regular
supervision and support to orphans without families. The support starts
before parents die and includes the development of memory books for
parents to leave with their children, the planning of the care of
orphans with extended family members, and the handing over of family
businesses or membership in community banks.
As a global community we must continue striving for available
medications for treating AIDS, a universal prevention vaccine, and the
interruption of maternal-to-child transmission. In addition to these
medical interventions we must continue to struggle with deep root
issues engulfing AIDS: early experimentation of sex among youth, adult
sexual exploitation of youth, the vulnerability and powerlessness of
many women, stigma, the lack of communication, commitment, respect, and
honor in many marriages, economic and social destruction of families.
B. Training
The tenets of training that transform are interactive involvement
of the trainees, training that is held in the local environment,
utilizing people's own readily available resources, training that
builds on beliefs and provides reflection and guidance toward
understanding truth when beliefs may contradict fact, and opportunity
to act on the lessons learned.
A challenge for NGOs has been to work with some faith-based groups
where AIDS is considered a curse or the condom an evil object. When
time and effort are taken to meet people on their own terms, using
their own community, religious, or family structures, very traditional
beliefs can be discussed. Building trust is critical to deciphering
error in erroneous traditional beliefs about AIDS. Some religious
communities in Kenya began to change some of their views and reduce
stigma associated with AIDS through training and role models of key
leaders. A lesson learned in a large USAID/AIDSCAP project in 1996
demonstrated that change does occur among church leaders when sources
of information can be trusted by church leaders, and they are given
opportunity to dialog together.
Training is effective when a variety of training tools are
utilized. We have developed mass media radio spots in Rwanda, an
interactive video in Malawi and Kenya, low literacy flip charts in
Malawi, and curricula for youth and micro-enterprise development. All
of these tools have had no ``shelf life'' and are in demand for
reprinting, adaptation and distribution throughout Africa, and some
countries in Latin America and Asia.
C. Networking and Collaborating
None of us have the answers or the abilities to fully apply the
answers we are discovering. We need each other.
We actively support cross-sectoral collaboration and have attended
the monthly meetings of the Private Voluntary Organizations Steering
Committee on HIV/AIDS at USAID. We have facilitated getting HIV/AIDS on
the agenda of the practitioner networks to which we belong: the Small
Enterprise Education and Promotion (SEEP) Network and the CORE network
whose focus is maternal and child health. Both of these networks now
have working groups to promote the HIV/AIDS agenda and to explore how
they can work together more efficiently and effectively.
We also encourage this dialogue at the national level. For example,
in Cambodia and the Philippines, World Relief has sponsored forums that
bring the economic and health sectors together to discuss cross-
sectoral collaboration for HIV/AIDS. In Rwanda, we helped establish the
Rwanda Microfinance Forum, a group well aware of the economic issues of
HIV/AIDS, addressing economic coping strategies and promoting AIDS
education to member organizations. We have worked hard to integrate an
appropriate response to HIV/AIDS into our microenterprise development,
maternal-child health and youth programs to realize greater impact and
more efficient use of our resources.
World Relief helped form a network of local and international NGOs
in Malawi that were not only HIV/AIDS specific, but multi-sectoral. The
network meets quarterly to inform each other of events, materials
developed and lessons learned.
In Kenya, our staff was on the organizing committee of the Kenya
AIDS NGO Consortium (KANCO) with present membership over 100 local and
international NGOs working in Kenya.
Information is vital to share. For that purpose we attend and
present at international forums including the global International AIDS
Conferences, the International Conference on AIDS and STDs in Africa,
the Microcredit Summits in Asia and Africa, and the Prescription for
Hope Conference in Washington, DC.
Collaboration begins at home. Nurses from New York City are keen to
not only continue learning about home care initiatives in Africa, but
also want to volunteer themselves to help. In this meeting in Manhattan
just weeks after September 11 these nurses drank in all they could
learn about AIDS in Africa and determined to support the efforts of
their nurse colleagues in Kenya. In other areas, children in Virginia
are sewing simple bed pads to help control skin problems resulting from
diarrhea.
iv. conclusion
In 1974, I was powerless while being held hostage by terrorists,
taken because I was an American. Today, I am strengthened because I am
an American who, together with you and those you represent, have power,
influence and money to change the course of millions of Elizabeths and
families with AIDS whose deaths in the first decade of the 21st century
alone will rival the number that died in all the wars of the 20th
century. [Remarks prepared for delivery by Vice President Al Gore at
the UN Security Council Session on AIDS in Africa, January 10, 2000].
Join the NGO community in their grassroots assault on the terror of
AIDS. Embrace the responsibility and challenge before us as Americans.
The Chairman. Thank you very, very much.
I know that Sir Elton John has to leave in just a few
minutes, so I will ask my colleagues if they have particular
questions for you, and then we will excuse you if that is all
right.
I would just like to ask you one question for a brief
response. You have been enormously generous with your time.
You talked about the importance of resources, and that is
obviously one of the major factors that have been reviewed by
yourself, Sandy Thurman, and others. What other kind of
leadership do you think the United States could provide? You
have had a chance, obviously, to talk with people in all parts
of the world. Resources are a major factor, and they may not be
the answer to everything, but it is a clear indication of a
nation's priorities, and we cannot minimize that. But what else
would you say that you would expect from the United States in
terms of leadership?
Sir Elton John. I think the fact that this committee would
even consider granting money and extra money to much-needed
projects throughout the African continent--all eyes seem to be
on America. This is a great country. You believe it is a great
country, and we believe it is a great country. I think that by
showing the compassion--the money is one thing, but the
humanitarianism and compassion is another. And America always
has been a compassionate Nation.
And I think just the publicity that one gets from things
like today shows that America cares. All the resources in the
world does not take away from the fact that if someone cares,
and someone wants things to happen, that is so important as
well.
I was very moved by the last speaker, and she was very
proud to be an American serving in Africa. That is an
advertisement in itself for this country.
I just think that when the reports are made today, just the
fact that you are sitting down today, and you care so much as a
committee is an incredibly important thing. Compassion these
days seems to be in short supply following the events of the
last year. There is a lot of anger and hatred in this world,
and I think compassion is the strongest form to combat that,
and you show that as a committee.
Thank you.
The Chairman. Thank you.
Senator Clinton.
Senator Clinton. Thank you so much.
Sir Elton, I want to ask you specifically about what you
have done in Brazil, because there is often debate that we
cannot--it is what we call a ``chicken and egg'' problem--we
cannot provide the care and treatment because we do not have
the infrastructure, but we do not have the infrastructure so we
cannot provide the care and the treatment. You were really in
on the ground floor with your foundation in Brazil, and as I
understand it, you created a program even where the country was
not yet ready to face up to some of the implications of the
HIV/AIDS pandemic, and by demonstrating that it worked, you got
the government to respond.
Could you describe that?
Sir Elton John. Well, it is a bit like matching grants,
when you fund a grant and get it matched by people. The
initiative in Sao Paolo was an extreme success, but it was not
done with the government's help. It was done entirely from our
organization and with the help of other people. And when the
government saw that it was a great success, they helped as
well. You set the example. You cannot sit back and wait for
things to happen. You have got to go in there. We always
investigate everything we do. We send a team out to make sure
that our money is being put to the best possible use, and we
thought this was an incredible opportunity to do something in
Sao Paolo, and it proved to be a huge success. By taking that
initiative--you have to take the initiative with this disease;
you cannot wait for people to say, ``Oh, no.'' Look at the
epidemic that happened in this country in the early 1980s. The
government really did not take any initiative at all, and it
was up to people to demonstrate their anger and to say,
``Listen, we need action.''
I think you have to take the initiative sometimes, and then
you get people to thinking, ``Oh, that works really well. We
will help.''
We are a very small organization, but we have funded over
53 countries, and we do make sure that in everything we do, the
money is really well-spent, and if the success of the venture
is apparent, people always take notice. That is all that we can
do, really.
Senator Clinton. Thank you.
The Chairman. Are there any other questions for Sir Elton?
Senator Warner.
Senator Warner. Thank you, Mr. Chairman.
Sir Elton, our job, those of us who take an active role in
this and have and will continue to do so, is to convince a lot
of colleagues. In just a few simple, understandable words--you
are approaching a fellow colleague as if you were a Senator--
how would you describe the race in terms of the rapid
proliferation and expansion of HIV/AIDS, both here domestically
in our country, and worldwide, but particularly worldwide; and
how fast is the catch-up procedure of medicine and health? Is
it not a widening gap between the efforts thus far to attenuate
and cure and the race of the disease in terms of its
proliferation?
Sir Elton John. Well, we do have a lot of catching up to
do. I would approach someone--if one could precis the doctors'
statements and Ms. Dortzbach's speech, which was the most
moving testimony you could have--I think you have to approach
someone who is skeptical by consistently clubbing them over the
head. I mean, we have been talking about this disease for so
long, and it has been well-publicized. This epidemic, this
pandemic, has had a lot of publicity. But as someone said at
the beginning, people still do not seem to get it; they do not
seem to get the implications healthwise, economically, and
socially, the impact that this is going to have.
You just have to keep on and on and on at these people who
are the doubting Thomases of this world. You have already
converted Mr. Helms, which is an incredible achievement, and
who would have thought? [Laughter.]
So I defy anyone to be uncompassionate in regard to this
disease.
Senator Warner. Again, am I correct in the assumption that
the proliferation of this disease is outpacing the efforts to
try, scientifically and medically, to care for it?
Sir Elton John. At the moment, yes. And unless we do
something very quickly, it is going to escalate even further;
absolutely.
Senator Warner. Thank you.
The Chairman. Senator Frist.
Senator Frist. Thank you, Mr. Chairman.
Sir Elton John, thank you for being here. In my opening
remarks, I said that I really do think we have an opportunity,
a challenge, and appropriately corrected by my colleague to my
right, Senator Warner, an obligation. And you really represent
a voice that goes much beyond the voice that we have as
political figures. I speak to that because we do have access to
money, and the case needs to be made. But your voice goes to
what we learn when we are in Uganda and what we learn when we
travel around the world, and that is the importance of having
leadership, recognized public figures, presidents of countries,
stand up and say it is important. It is something that is hard
for politicians to do, as my colleague was saying, and your
comments about the importance of us as representatives standing
up, even if it is unexpected.
Many of us have had the opportunity to meet with President
Museveni in Uganda and Muluzi from Malawi and people who have
stood up and, at the beginning of every speech they give, no
matter what the subject, say ``this is the number one
priority.''
You see more leaders than we see as you travel around the
world. What advice do you have for us in talking--because if
you do not have the leaders of a country today, including this
country but including the recipient countries where the
incidence is high, or countries where the rate of growth is
high--how best can we get the leadership of those countries
involved, and what has your response been in terms of--when you
mention your foundation, when you mention HIV/AIDS, to people
like in South Africa, the leadership there, who might not quite
fully want to approach the issue in the way that you do?
Sir Elton John. I am just basically an entertainer. I am a
quite well-known entertainer, but I am quite aware that when it
comes to clout and speaking to politicians, I am an
entertainer. I have no delusions about what power I have or how
I can convince people.
I think you have to take it to the grassroots level. For
example, in Africa, the best way of dealing, I think, with it
is getting people like me, or heroes, involved--people who are
sports idols, people who are idolized by young people, people
whom they will listen to--in Africa, soccer players, for
example, African soccer players. If you cannot get to the
government, and you cannot change the policy of a government,
then start somewhere else. Start at the grassroots level. Get
young people's attention by getting the people who are their
heroes involved. Then they will listen.
For example, in this country, Magic Johnson is a prime
example. He is a great example to young people everywhere in
this country, not only African Americans, black Americans. It
was an incredible thing to happen; people respected him, and
people listened to him.
To make a difference at that level, yes, one can always go
to the leader of a country, but it is awfully difficult. It is
not easy for me to knock on a door and say, ``Oh, by the way, I
am popping in for a cup of tea.'' It is not as easy as that. It
is much easier to use one's celebrity and one's success in a
local area to get people involved.
This is what I intend to do in Africa when I go there, to
take people who are idolized by African kids, whom they will
listen to. I always think that young people will always listen.
I think that young people are very attentive, very intelligent,
and they will listen if they are taught and instructed the
right way. And who better to tell them than someone whom they
completely look up to?
The same for Russia as well. I intend to go to Russia next
year and do the same thing.
So that is the way that I can do it.
Senator Frist. I think that is very well said, and many of
us have had the chance to work with people on this panel and go
into the countries directly. I have tremendous faith in young
people, and you have more access to them than we do, and we
appreciate your work.
Let me just close and say that what I am going to take away
in terms of your comments today is what you said about at the
end of the night--whether it is entertaining and what you do,
or whether it is we as political figures today--when the lights
go out, and when you go to bed at night, or 10 years from now
when people look back, there is no question that the question
is going to be asked, ``Did you do everything possible?'', and
history is going to judge us as a Nation and as a global
community as to how well we are both addressing and responding
to this most devastating and destructive plague, as Sandy
Thurman said, a plague of epidemic proportions.
That is the image that I am going to carry away--when the
lights go out, when we go home for recess, leave the United
States Senate, do something else, history is going to judge how
well we respond.
So thank you for being here.
Sir Elton John. Could I just say one more thing? I am 55
years of age, and I have made a commitment for the rest of my
life to do something for this disease. If we all come together
to make that commitment, we will have no conscience, because we
will have done that.
If people come together, like this committee, like the
people who are testifying, and we roll ourselves like a ball of
wool and eventually get to the size of the Indiana Jones
thing--if you remember that huge thing that went down--it is an
unstoppable thing. Commitment en force, en masse, is an
incredible thing.
I have made a commitment for the rest of my life that I
will do something for people with AIDS. If we all pull together
and do something like that, and we all do it together, we will
make the difference--there is no question.
Senator Frist. Thank you.
Thank you, Mr. Chairman.
The Chairman. Senator Sessions.
Senator Sessions. Thank you for that commitment. It has
made a difference.
I talked to a businessman who does a lot of work around the
world, and he said that in developing nations, the absolute key
is not to give the money too high up the ladder. If you are
giving the money to the people doing the work, they will work
wonderfully, and things will happen beautifully. If you give it
too high up, it does not get to the people who do the work in
an effective way.
Many of you have foundations and are leading groups that
are smaller, where you can be more effective. We are talking
about, if we were to do what Ms. Thurman asked, tripling our
contribution to $2.5 billion.
Do you have any suggestions as to how we can make sure that
that money actually reaches its greatest potential?
Sir Elton John. I concur with you totally. What that money
has to go toward is training people to build an infrastructure
so that people can get the drugs they need in remote parts of
countries, and it needs to be run on a government level. But I
know what you are saying. I do not know how you do that,
because I am just a singer. This is something that the
politicians have to make sure that when the money goes to
governments, the money is spent in the right way.
I have said before that we are a very small AIDS
organization; we can control where everything goes, and we do.
We know where every penny goes. But when you get to these vast
sums of money that we are talking about here today, you are
going to run into those kinds of problems, and I do not
personally know myself how you solve them, but I do concur with
you that that is a major problem.
Senator Sessions. Thank you.
The Chairman. Thank you, Sir John. We know that you have
other appointments, and we are very grateful for all the time
you have given. If you need to be excused, we will excuse you,
and we will take a few more minutes for questions of the other
panelists. We hope you are not going to go beyond our call and
that if we need you again, we can--
Sir Elton John. Please use me as much as you feel you want
to use me.
The Chairman. Good. Thank you very much. If you do have to
leave, we will understand.
We have a short time remaining, so maybe we can each ask a
question, and we will try to go as long as we can.
If we say that one of the issues is the financial, would
you say that the second one is the cultural, and what kind of
progress are we making in terms of working through some of
these cultural differences?
Let us start with Dr. Mugyenyi, if you would comment, and
then perhaps other members of the panel would like to say a
word as well on the progress that has been made, the
difficulties that we are facing, and any suggestions or ideas
that you have to help us deal with these issues.
Dr. Mugyenyi. Thank you, Senator Kennedy.
The most important issue here is not to plan a program
outside the developing countries and carry it over there. This
normally faces difficulties. The most important aspect of
culture is to work with the people, so that the planning stage
involves the indigenous people, that is, the people who are
going to get the aid, and the advice on how aid is to be used.
It helps address the issue that has been brought up of the
higher-ups not taking the money to the grassroots when the
planning involves the people. So this is the crucial aspect of
this, Senator.
Another important issue in culture is information. It is
very important that there is an atmosphere of openness in how
AIDS money is used, so that the people themselves become the
guardians of good use of the money, and they can only do so
once they are informed that such amount of money is available
and that such programs have been implemented.
The Chairman. Can we hear from Dr. Rosenfield?
Dr. Rosenfield. I would just like to reiterate what Peter
has said. There is no question that we cannot take a model from
the United States and simply impose it. We have to deal with
local groups, and local groups have to take the leadership in
developing a culturally sensitive or culturally appropriate
approach to any health intervention, and particularly one as
sensitive and difficult as the AIDS epidemic.
We have seen a wonderful program in South Africa called
Love Life, focused on youth, a superb program building on the
experience of youth themselves in that particular setting. We
need to see programs like that in each country in which funds
are allocated.
The Chairman. Ms. Dortzbach.
Ms. Dortzbach. Utilizing the principles that Dr. Mugyenyi
has described, we have seen a dramatic change in Rwanda with
church leaders who at one time were very stigmatizing,
reluctant to even mention the word AIDS, and said, ``It is not
with us.'' Now, today, as a result of a lot of training, a lot
of patience, a lot of advocacy work, there are 180 different
support groups for people living with AIDS who are within those
same churches.
The Chairman. Ms. Thurman.
Ms. Thurman. Simply to add to that that what we saw in the
early days of the epidemic here reminds me in large part of
what we are seeing in Africa, and that is that the response had
to be homegrown, it had to be based in the community and then
supported by Federal and State dollars.
I think it addresses what Senator Sessions was saying, that
in the Ryan White CARE Act, what made it so successful was the
fact that the money came from the Federal Government but went
directly into community-based organizations and not through
some cumbersome Government process, so that the cultural
issues, even at the domestic level, in the communities hardest-
hit early on could be dealt with in very sensitive ways.
The Chairman. I can remember the difference in the cost. In
San Francisco, it was about $30,000 to $35,000, and in Boston,
about $120,000. So we found out how to really do this and do it
right.
Senator Clinton.
Senator Clinton. Thank you very much.
I want to be sure that I understand the specific
recommendations that each of you would make to us, because as
we attempt to craft legislation out of this committee, out of
the Foreign Relations committee, and out of other committees
that are involved, I hope that we fully appreciate the ideas
that you have brought to us.
So to that end, I just want to confirm that in your written
testimony, Ms. Thurman, you have specific recommendations
regarding the role that the Centers for Disease Control could
undertake, including a treatment set-aside which would provide
a Federal match of any private funding to expand MTCT programs.
I understand that that is one of your recommendations. Is that
right?
Ms. Thurman. It is. We are recommending that at least $500
million be given to CDC to expand their prevention efforts, and
then also to expand their care and treatment programs and
support and match what the private foundations that Dr.
Rosenfield has talked about are doing.
Again, I think this whole idea of public-private
partnership at this point in time is very important, and the 30
percent set-aside that we are talking about for treatment would
include that $100 million to match what the foundations have
done to expand the programs to prevent mother-to-child
transmission to treat mothers and other family members.
Senator Clinton. And that would correspond as well with Sir
Elton's recommendation, as well as Dr. Rosenfield's
recommendation, about private initiative being given that kind
of match.
Ms. Thurman. Yes.
Senator Clinton. In addition, you recommend that HRSA,
which is one of our Federal agencies that now does a lot of
work under the Ryan White CARE Act, be more involved in the
developing world; so we would use the expertise that we have
already developed here and export that.
Ms. Thurman. Exactly. We do not need to reinvent the wheel
at this point.
Senator Clinton. Third, you recommend that the committee
authorize and try to push a workplace-based HIV/AIDS program
through both the CDC and the Department of Labor that would be
used in other countries to try to do workplace education along
the lines of what has been done in Uganda, Senegal, and other
successful programs; is that right?
Ms. Thurman. Exactly, and that is particularly important
where we have anywhere between 5 and 30 percent of the work
force infected. Using organized labor and the workplace is our
best way to reach those people.
Senator Clinton. Similarly, both Dr. Mugyenyi and Dr.
Rosenfield mentioned the availability and cost of AIDS drugs.
This is a difficult challenge, but it is one that we have to
address. I think that both with respect to the generally
available effective AIDS drugs and the MTCT-Plus program, we
are going to have to tackle this in one way or another. It is
very troubling to think about the future, because certainly we
are focusing today on Africa, but there are many experts who
increasingly are telling us that the pandemic is alive and well
and spreading in Asia, particularly in India, increasingly in
China, and in Russia. So, trying to get ahead of the need for
drugs and figure out a way to provide them in a cost-effective
manner is critical, I assume.
I very much appreciated Ms. Dortzbach's testimony on the
role of microcredit and the role of family financing, which is
something that I believe in very strongly and have worked on
for more than--oh, my gosh, a long time--20 years, I guess. And
I had not really thought about including microcredit as part of
our overall comprehensive AIDS strategy until you mentioned
that, Ms. Dortzbach. I think that is something that we really
ought to look at, because it goes hand-in-hand with self-
sufficiency, with economic activity, which is an important part
of dealing with this crisis. So I very much appreciate your
description and recommendation on that.
Mr. Chairman, I think we have some very positive
suggestions from this panel in addition to their very moving
testimony and their own personal commitment. I think we have
some ideas that we can get to work on in this committee and can
work on with other committees as well.
Thank you.
The Chairman. Very good. Thank you.
Senator Frist.
Senator Frist. Thank you, Mr. Chairman.
I would like to come back to two questions, and one, I will
direct to Ms. Thurman about the AIDS orphans issue, and then,
Dr. Mugyenyi, I want to ask you about the testing component of
linking prevention, care, and treatment with testing. When I
was with you several months ago, the most remarkable thing that
I learned on my last trip to Africa 2 months ago, to Uganda, to
see, as Senator Clinton did, the tremendous service in track
record, but also culturally-oriented service that you offer
there--it was remarkable to me to see the change versus 3 years
ago in terms of rapid testing, VCT, voluntary. We have
mentioned it in the hearing this morning, but it was remarkable
to me that we have been able to condense a test which costs $50
to $60 in American dollars and used to take several weeks--
where you lost that ``teachable moment.'' The voluntary part
amazed me that it worked so well. The counseling part is the
education that we have all mentioned. The testing part, the
technology, and the role that technology has played in taking
an expensive test that took several weeks, where you lost the
``teachable moment,'' you might not be able to see that
individual once again--now, with the test down to $1.20, with
certain sensitivity and certain specificity combined in that 1-
hour or 45-minute period, you can capture what a physician
knows as the teachable moment where somebody who comes seeking
information, is receptive, you can give that information and
while you are there discuss, whether it is behavior, whether it
is treatment options, and again, Sandy Thurman's linkage
between prevention, care, and treatment is so critical from a
physician's standpoint as we go forward.
Before I have you answer that, let me ask the second
question which has to do with the orphans. Father D'Agostino is
in the audience today, and many of us have had the opportunity
to visit with him on numerous occasions and have seen the
tremendous work that he does. When you see the AIDS orphans--
and you are almost embarrassed to call them ``AIDS orphans,''
because you see their faces and the delight and the love that
he has been able to give them and that they can express--yet,
as you said in your testimony, we are going to have 40 million
AIDS orphans in the next 40 years.
If you could just address what we can do, and Dr. Mugyenyi,
could you comment on the testing, the technology, and the
impact it has had.
Dr. Mugyenyi. Thank you, Senator Frist.
That is a very, very important issue, because for a long
time, it was thought that Africa would not make headway because
it had no technological means of testing for HIV/AIDS and
monitoring for antiretroviral drugs.
Testing has indeed made a revolution in Africa. A person
comes into our clinic, and just within the same day, in fact,
within an hour, we will have had counseling, he will have had
discussions with a few other people who are prepared to be
available on that day, and then he will get the results on the
same day and then see physicians in the same small center that
you saw and be able to have a description of how to go forward
with treatment.
This can be repeated in many parts of Africa, and we are
very proud that we are part of the groups that developed this
method.
Another very important question related to testing, Senator
Frist, is the expensive monitoring tests. It is embarrassing,
Senator, that these tests are now more expensive than the drugs
themselves.
Senator Frist. Could you tell us roughly, in terms of
testing for VCT, how much do those little tests cost,
approximately?
Dr. Mugyenyi. If you use the conventional method of testing
for CD4, you pay about $60.
Senator Frist. And this is for the monitoring.
Dr. Mugyenyi. Just for the CD4.
Senator Frist. First of all, for the voluntary counseling
and testing, when somebody comes in, HIV-positive or not, about
how much does that cost today?
Dr. Mugyenyi. It costs about $200 to do both CD4 and
virology testing.
Senator Frist. For VCT, though, for the voluntary
counseling and testing, if somebody walks in the door, and they
just want to know if they are HIV-positive, to do the screen
for them costs how much?
Dr. Mugyenyi. Oh, in our center now, it is down to $1.
Senator Frist. One dollar. That is just unbelievable. And
you can get the result immediately.
Dr. Mugyenyi. Yes.
Senator Frist. The second issue you talked about is
monitoring, which is the immunologic monitoring over time. How
much does that cost now?
Dr. Mugyenyi. That is very expensive, but Senator, in my
center, we no longer use those methods. We have, together with
American scientists and other scientists, discovered that we
can do effective testing using more cost-effective methods. We
can now do it for under $30.
Senator Frist. Thirty dollars. Is that for a year, or per
test?
Dr. Mugyenyi. Per test.
Senator Frist. Per test. And how many tests per year?
Dr. Mugyenyi. We just need two tests per year.
Senator Frist. Thank you very much.
Ms. Thurman. And looking at the issue of orphans, I think
there are a lot of things that we can do. It is sort of mind-
boggling to think that we will have 40 million children
orphaned by AIDS. Certainly, Father D'Agostino has done
extraordinary work in the orphanage that he runs, but in
addition to the orphanage, he has an incredible outreach
program, and I think that that is where we have to focus most
of our attention, because with 40 million orphans, we are going
to have to keep them in communities. In addition to that, we
all know from decades of study that children thrive better if
left in their own families and in their own communities, and
not put in institutions. That needs to be a last resort for us.
So I think there are several things that we can do. We need
to give the families support that are caring for orphans. We
need to look at microfinance programs like the program that the
First Lady of Uganda has started to mobilize, grandmothers who
are actually inheriting the care of many orphans when their
children die. We need to look at supporting school fees for
children, training caregivers. I think we need to prepare the
children for the death of their parents. That is something that
costs very little, but in terms of their psychology development
long-term, it is very, very important when we can to prepare
these children for life without their parents; and again, that
costs very, very little.
So there are a lot of ways and very cost-effective ways
that we can support those children and try to keep them in
their communities when we can, but education of these children
and school fees is going to be very important, because if they
have no means of support, they are going to be very, very
vulnerable. So we need to look at that impact as well.
Dr. Rosenfield. Senator Frist, could I just add one point?
With both the MTCT-Plus initiative and the major, much larger
initiative of the Global Fund, we can prevent 40 million
orphans over the next 20 years if we take this pandemic
seriously now and put in place programs both to put MTCT alone
in place to decrease transmission rates, treat the mothers so
that the kids are not orphaned, and begin the broad treatment
programs.
I would urge the committee to support not only the
initiatives that we have talked about, but Kofi Annan's
eloquent call to action for his Global Fund; and the United
States should be taking, I believe, greater leadership in the
support of the Global Fund, because that is the long-term hope
that we will not end up with 40 million orphaned children and
that we will reverse the absolute death rates that exist now
for everybody who is HIV-positive in Africa, Asia and
elsewhere.
I do agree, Senator Kennedy, that the figures in India and
China are probably significant underestimates of how
significantly that epidemic has already reached South and
Southeast Asia.
So just think--if India had 5 percent seropositivity, well
below some of the rates in Africa, with a billion people, the
mathematics there are just mind-boggling. And we are heading
there if we do not get ahead of this process, both in
prevention and care.
The Chairman. The vote has started, so we have about 4 or 5
minutes.
Senator Warner.
Senator Warner. I will be very brief.
Dr. Rosenfield, we are going back and forth,
understandably, between the problems abroad and the problems
here at home. Ms. Thurman had an opportunity to respond to
questions from Senator Kennedy about the domestic situation. Do
you wish to add anything about the domestic situation?
Dr. Rosenfield. Yes. I think it is obviously at a different
level than in Africa, but it is a major issue. It has become
predominantly an issue of people of color. I chair the New York
State AIDS Advisory Council, and we deal with this all the
time. We continue to have deaths. People do break through from
treatment.
We need a greater focus and a greater allocation of
resources to those who are at highest risk in this epidemic in
our country, and that includes the IV drug-using populations,
those exposed to those drug-using populations. We see a return
among men who have sex with men, particularly younger people
who are not believing the stories of older people.
So we do have a heavy challenge still in our own country as
well.
Senator Warner. Thank you.
Dr. Mugyenyi, I mentioned the political and military
instability in a number of nations. Can you comment on that? It
is the inability to raise and sustain not only internal
military forces but internal police and otherwise, which are
essential to any government to carry out its policies.
Am I correct that this disease is a direct contributor to a
great deal of instability in both of those areas, political and
military?
Dr. Mugyenyi. Yes, Senator. This is a very destabilizing
factor in our part of the world. The soldiers who are sick are
not able to defend their countries; the lack of drugs for a
disease that is most important to the people is causing
agitation. You have seen the situation in Southern Africa. It
is the most important political issue after being the most
important health issue.
So you are absolutely right, Senator, that this is not only
a health factor but also a highly destabilizing factor in our
part of the world.
Senator Warner. Mr. Chairman, if those witnesses with us
today or others following this important hearing have further
contributions in that area of political-military instability, I
would be happy to review them, and suggest that portions might
go into today's record.
The Chairman. Thank you.
Senator Sessions.
Senator Sessions. Thank you, Mr. Chairman.
Dr. Rosenfield, maybe we could summarize a little bit here
on some of the things that we have discussed.
How much does it cost--well, let me ask this--what
percentage of children with untreated mothers who have AIDS are
born with the disease, and what can be done if the mother has
the medication, and how much progress in reducing that
infection rate can be achieved?
Dr. Rosenfield. Without treatment, the transition rate is
estimated to be somewhere between 25 and 40 percent. With the
simple nevirapine therapy to the mother, a single dose, and the
single dose to the baby, we can beat that by at least 50
percent.
Senator Sessions. And that is a $4 dose, approximately? How
much is it?
Dr. Rosenfield. It is something in that range. So we can
change that by at least 50 percent.
Senator Sessions. And Ms. Thurman, I think you were
suggesting that we need to go further than that and deal with
the mothers and fathers who are dying of AIDS, and that
treatment could prevent these children from becoming orphans.
Ms. Thurman. It is true. I think that if we treat the
mother--and hopefully the fathers, because it creates bad
family dynamics if you are treating the mother and not the
father--but certainly treating the mother, we again know from
years of research that the longer we can keep those infants
with their mothers, the more viable they will be in the long
term. So that is what we are asking CDC and what Dr.
Rosenfield's MTCT-Plus program aims to do, and that is to
provide treatment to mothers and other family members so we do
not create orphans, so we keep families together. It is about
celebrating and supporting the families.
Senator Sessions. Let me ask this. What percentage of
pregnant women with AIDS are being treated with the drugs? Does
anyone konw that?
Dr. Rosenfield. With nevirapine today?
Senator Sessions. In Africa.
Dr. Rosenfield. It is a very small percentage. The program
is only 3 to 4 years old. The Glaser Foundation has taken a
lead in this, and UNICEF and others are actively involved, but
it is still a small program and in need of great additional
resources.
I could not give you a percentage, but it is a very small
percentage of the total number of women who are currently HIV-
positive in Africa.
Senator Sessions. So with a $4 treatment, we could
dramatically reduce the number of infants born with AIDS, and
we are just not reaching those pepole.
Dr. Rosenfield. Yes. Certainly, additional funding is
needed, but the groups, again, like the Glaser Foundation,
UNICEF, Medins Sans Frontiers, CDC, and others, are moving as
quickly as they can to work with governments to try to expand
these programs.
Senator Sessions. Well, that is a challenge.
Thank you.
The Chairman. Thank you very much.
Again, all of you have been enormously interesting. We will
have all of this as an amendment to the Foreign Relations
Committee legislation that will be considered. Also, we will
all be supportive in terms of these funding mechanisms, and it
may come out somewhat differently in terms of different members
of the committee, but I think you have a strong sense that we
are all going to do as much as we possibly can. That is
probably the best way we can thank you very much for a really
extraordinary presentation.
We hope that as many of our colleagues as possible will
read through the record and review what has been said, because
it is enormously persuasive and compelling.
I just want to mention that we do have here with us today
Ann Blackmun and her son Christophe. Ann and her son have
worked tirelessly to bring attention to issues of families and
children with AIDS. Christophe recently focused on the plight
of children with AIDS in Kenya, and did a very outstanding
documentary on that. We are very thankful that they could be
with us today.
There being no further business, the committee will stand
in recess.
[Whereupon, at 12:19 p.m., the committee was adjourned.]