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55–398PDF 2010

U.S. INVESTMENTS IN HIV/AIDS: OPPORTUNITIES

AND CHALLENGES AHEAD

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA AND GLOBAL HEALTH

OF THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED ELEVENTH CONGRESS

SECOND SESSION

MARCH 11, 2010

Serial No. 111–104

Printed for the use of the Committee on Foreign Affairs

(

Available via the World Wide Web: http://www.foreignaffairs.house.gov/

(II)

COMMITTEE ON FOREIGN AFFAIRS 

HOWARD L. BERMAN, California, Chairman 

GARY L. ACKERMAN, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

DONALD M. PAYNE, New Jersey 

BRAD SHERMAN, California 

ELIOT L. ENGEL, New York 

BILL DELAHUNT, Massachusetts 

GREGORY W. MEEKS, New York 

DIANE E. WATSON, California 

RUSS CARNAHAN, Missouri 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

MICHAEL E. MCMAHON, New York 

JOHN S. TANNER, Tennessee 

GENE GREEN, Texas 

LYNN WOOLSEY, California 

SHEILA JACKSON LEE, Texas 

BARBARA LEE, California 

SHELLEY BERKLEY, Nevada 

JOSEPH CROWLEY, New York 

MIKE ROSS, Arkansas 

BRAD MILLER, North Carolina 

DAVID SCOTT, Georgia 

JIM COSTA, California 

KEITH ELLISON, Minnesota 

GABRIELLE GIFFORDS, Arizona 

RON KLEIN, Florida 

VACANT 

ILEANA ROS-LEHTINEN, Florida 

CHRISTOPHER H. SMITH, New Jersey 

DAN BURTON, Indiana 

ELTON GALLEGLY, California 

DANA ROHRABACHER, California 

DONALD A. MANZULLO, Illinois 

EDWARD R. ROYCE, California 

RON PAUL, Texas 

JEFF FLAKE, Arizona 

MIKE PENCE, Indiana 

JOE WILSON, South Carolina 

JOHN BOOZMAN, Arkansas 

J. GRESHAM BARRETT, South Carolina 

CONNIE MACK, Florida 

JEFF FORTENBERRY, Nebraska 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

BOB INGLIS, South Carolina 

GUS BILIRAKIS, Florida 

RICHARD J. KESSLER, Staff Director 

YLEEM POBLETE, Republican Staff Director 

SUBCOMMITTEE ON AFRICA AND GLOBAL HEALTH

DONALD M. PAYNE, New Jersey, Chairman 

DIANE E. WATSON, California 

BARBARA LEE, California 

BRAD MILLER, North Carolina 

GREGORY W. MEEKS, New York 

SHEILA JACKSON LEE, Texas 

LYNN WOOLSEY, California 

CHRISTOPHER H. SMITH, New Jersey 

JEFF FLAKE, Arizona 

JOHN BOOZMAN, Arkansas 

JEFF FORTENBERRY, Nebraska 

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C O N T E N T S 

Page

WITNESSES 

Peter Mugyenyi, M.D., Director and Founder, Joint Clinical Research Center . 11

Joanne Carter, D.V.M., Executive Director, Educational Fund, RESULTS 

(also Board Member of The Global Fund to Fight AIDS, TB and Malaria) .... 19

Ms. Debra Messing, Global AIDS Ambassador, Population Services International ................................................................................................................. 28

Norman Hearst, M.D., Professor of Family and Community Medicine and 

of Epidemiology and Biostatistics, Department of Family and Community 

Medicine, University of California, San Francisco ............................................ 33

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

The Honorable Donald M. Payne, a Representative in Congress from the 

State of New Jersey, and Chairman, Subcommittee on Africa and Global 

Health: Prepared statement ................................................................................ 6

Peter Mugyenyi, M.D.: Prepared statement .......................................................... 14

Joanne Carter, D.V.M.: Prepared statement ......................................................... 22

Ms. Debra Messing: Prepared statement ............................................................... 30

Norman Hearst, M.D.: Prepared statement .......................................................... 37

APPENDIX 

Hearing notice .......................................................................................................... 56

Hearing minutes ...................................................................................................... 57

The Honorable Christopher H. Smith, a Representative in Congress from 

the State of New Jersey: Prepared statement ................................................... 58

The Honorable Donald M. Payne: Statement of Ms. Vuyiseka Dubula, General 

Secretary, Treatment Action Campaign ............................................................. 63

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U.S. INVESTMENTS IN HIV/AIDS: 

OPPORTUNITIES AND CHALLENGES AHEAD 

THURSDAY, MARCH 11, 2010

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON AFRICA AND GLOBAL HEALTH, COMMITTEE ON FOREIGN AFFAIRS, Washington, DC. 

The subcommittee met, pursuant to notice, at 10:39 a.m. in room 

2172, Rayburn House Office Building, Hon. Donald M. Payne, 

(chairman of the subcommittee) presiding. 

Mr. PAYNE. We will bring the meeting of the Subcommittee on 

Africa and Global Health to order. 

Let me first apologize for the tardiness of the hearing. There was 

a mandatory caucus meeting held on healthcare, which I had to at 

least attend for a few minutes. It is still going on, and that is why 

members over here are not present. 

I understand Mr. Smith was here, and I was waiting to see if he 

could return, since he was here on time initially. But we do have 

time constraints, so I am going to officially open the meeting. And 

when Mr. Smith comes, I will allow him to give an opening statement, even after we begin with the witnesses. 

So good morning again. Let me thank you for joining the subcommittee here today—the Subcommittee on Africa and Global 

Health. It is a critically important hearing, entitled U.S. Investments in HIV and AIDS, Opportunities and Challenges Ahead. 

In 2003, Congress passed the United States Leadership Against 

HIV and AIDS, Tuberculosis and Malaria Act, authorizing, at that 

time, an unprecedented $15 billion for global HIV/AIDS, TB, and 

malaria programs. This landmark legislation laid out ambitious 

goals: Prevention of 7 million new HIV infection, treatment of at 

least 2 million people, and care for 10 million people affected by 

HIV and AIDS, including orphans and vulnerable children. 

With courageous bipartisan leadership, PEPFAR quickly became 

the world’s largest effort to combat a single disease in the history 

of mankind. In 7 years since Congress passed the original legislation authorizing the President’s Emergency Plan for AIDS Relief, 

or PEPFAR, it has become a historic program. 

The word PEPFAR is known throughout Africa. This program 

will be remembered as probably the most significant achievement 

of former President George Bush. 

Prior to PEPFAR, the United States did not support any type of 

AIDS treatment abroad. Officials in the administration said that 

treatment was not feasible in Africa. One excuse that was used, as 

many of us remember, was said because Africans could not tell 

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time, and therefore they would be unable to use the medication, 

and that we should simply limit our activities to the prevention of 

the spread of the disease. 

Then in 2008, Congress went even further, and PEPFAR won, to 

the amazement and surprise of many Members of Congress and the 

administration, and the world, when it reauthorized the program 

for another 5 years, at the additional level of $48 billion, to prevent 

12 million new infections, treat 3 million people living with HIV 

and AIDS, and care for 5 million orphans and vulnerable children. 

The bill also provided $4 billion to treat tuberculosis and $5 billion to treat malaria over the next 5 years. And it incorporated new 

and improved policy and programming mandates, including increasing the number of health workers in Africa, providing medicines for opportunistic infections, supporting nutritional programs, 

and removing some of the restrictions on funding to allow doctors 

and scientists to direct programming. 

PEPFAR programs have had a remarkable international impact. 

As of December 2008, approximately 4 million people in low- and 

middle-income countries were receiving anti-retroviral therapy 

(ART), about 10 times more than just 5 years ago. 

The number of new HIV infections among children has declined 

as a result of expanded access to medicine for the prevention of 

mother-to-child transmission (PMTCT). About 45 percent of HIVpositive pregnant women worldwide had access to PMTCT services 

in 2008. This is a significant improvement from the 10 percent that 

we saw back in 2004. 

Increasingly, we are seeing the benefits of our AIDS response in 

other areas of the health sector, including improving vaccination 

coverage, family planning, strengthening laboratory and health systems, as well as decreasing infant and maternal mortality. 

Despite tremendous efforts made by the United States and the 

international community, AIDS is still among the biggest infectious 

killers the world has ever seen. 

Sub-saharan Africa remains the region most severely impacted 

by HIV and AIDS. Over 22 million people were living with HIV in 

Africa in 2008, and 1.9 million of whom contracted the virus during 

that year. About 1.4 Africans died of AIDS in 2008, accounting for 

72 percent of all the AIDS-related deaths worldwide. 

Although the rate of new infections is slowly declining, the number of people living with the virus continues to grow, due, in large 

part, to greater access to anti-retroviral medications. 

While coverage rates have improved across Africa, mother-tochild transmission continues to account for a substantial portion of 

the new HIV and AIDS cases. It is unconscionable that children 

continue to be born with the virus, when we have the tools to prevent transmission. We must make it our goal to eliminate motherto-child transmission of HIV. 

I am deeply concerned about the reports that the fight against 

HIV/AIDS is faltering and continued rapid rollout of AIDS treatment is endangered in Africa. The economic crisis that has hit our 

nation and the world has also devastated the countries receiving 

our health aid, and calls for us to renew our efforts. And we must 

make sure that we don’t start to decline. 

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I certainly applaud President Obama’s announcement of a broad 

Global Health Initiative (GHI) with a pledge of $63 billion over 6 

years. That includes $51 billion for PEPFAR, a $4 billion increase 

over the 2008 authorization, and $11 million for maternal and child 

health, neglected tropical diseases, and an overall focus on building 

capacity of health systems. 

I look forward to working with the administration to make this 

vision a reality. I am especially pleased with the GHI emphasis, a 

focus on building the capacity of healthcare systems. I know that 

Dr. Goosby will ensure this initiative, and he will certainly continue to be a strong advocate in the fight against HIV and AIDS. 

And I don’t think a more qualified person could have been selected 

for the very important position. 

At the same time, let us all remember that the advances in funding levels and reach of U.S. programs can be greatly leveraged 

through investment in national health systems. And we have seen 

that, but we have to know that we are strengthening health systems in other countries, so that when we do decrease funding, perhaps in the distant future, there will be strong health systems in 

those countries. 

In his 2010 State of the Union, President Obama addressed the 

reason for our efforts to fight HIV and AIDS: ‘‘America takes these 

actions because our destiny is connected to those beyond our 

shores. But we also do it because it is right.’’

Despite our economic challenges, we must continue to reach out 

to other countries in need, not just because it is in our best interest, but because it simply is the right thing to do. 

I look forward to the continued evaluation of our efforts to combat this devastating disease, and I sincerely thank the panel of esteemed witnesses for testifying before us today and sharing their 

insights on what we, as a nation, should be doing and what more 

we can do to address this issue. 

Before I turn to the ranking member for his remarks, let me 

allow him to catch his breath. And let me also state that we look 

forward to having Dr. Goosby, the U.S. Global AIDS Coordinator, 

before this committee. Chairman Berman would like him to testify 

before the full committee at a later date, and ask that we hold off 

until he is able to do that. Therefore, this panel will only have a 

private panel. And at a future hearing, we will have administrative 

officials. 

And now I will turn back to Mr. Smith. I appreciate him being 

here earlier. I mentioned there was an emergency meeting that 

was called. I stayed just to be checked in, and came over then. But 

I am glad you are here again. Thank you. 

Mr. SMITH. Thank you very much, Mr. Chairman. I want to 

thank you for calling this very important and very timely hearing 

to explore the future of the President’s Emergency Plan for AIDS 

Relief, or PEPFAR. 

As you know, the Leadership Act originally passed with the sponsorship of Henry Hyde and Tom Lantos, and you and I and several 

others, but they were the lead; and was signed into law by President Bush, who initiated this historic health initiative in 2003, 

with very strong bipartisan support. 

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It has been extraordinarily successful in countering the devastating toll that the HIV/AIDS pandemic was taking on, and is 

continually impacting women, men, and children throughout the 

world, most particularly in Africa. 

The United States’ bilateral funding has provided lifesaving antiretroviral treatments for over 2.4 million individuals—over half of 

the nearly 4 million persons receiving treatment in low- and middle-income countries. It has directly supported care for almost 11 

million people affected by HIV/AIDS, including 3.6 million orphans 

and vulnerable children. 

Almost 340,000 babies have been born without HIV, even though 

their mothers were HIV-positive, thanks to PEPFAR’s mother-tochild transmission prevention programs; and an incredible 29 million people have received PEPFAR-supported HIV counseling and 

testing. 

To achieve these results, as well as to make annual contributions 

to the Global Fund to fight AIDS, TB, and malaria, and related 

programs to treat tuberculosis, the U.S. has dedicated over $32 billion since 2004. The African people, who have been the prime beneficiaries, are well aware of the American taxpayers’ generosity. 

During my travels to Africa I have been repeatedly overwhelmed 

with gratitude from people of all ages and walks of life, who credit 

George Bush and the American people and the Congress with saving their lives, their families, and their communities. 

However, Mr. Chairman, it is critical that we take this opportunity to step back and examine the best way to move ahead. As 

the title of this hearing indicates, there are significant challenges, 

as well as opportunities. 

One challenge is in respect to how treatment will be provided to 

new patients over the coming years. Estimates of the rate of new 

HIV infections, compared to those obtaining treatment, range from 

between two to one and five to one. 

While Congress authorized $39 billion in the 2008 reauthorization, for 2009 to 2013, even this amount cannot fully cover the 

growing need. It is apparent that our country cannot carry this increasing burden, alone. I look forward to hearing our distinguished 

witnesses’ proposals for resolving that dilemma. 

At issue with respect to PEPFAR, and I find this particularly disturbing, is the administration’s proposed implementation of the socalled Prostitution Pledge. The purpose of this pledge, created to 

ensure compliance with PEPFAR, a PEPFAR mandate, is to prevent PEPFAR funding from being misdirected to those who refuse 

to oppose prostitution and sex trafficking as a matter of policy. 

Prostitution and sex trafficking exploit and degrade women and 

children, and exacerbate the HIV/AIDS pandemic. Yes, despite a 

clear statutory mandate based on an equally clear U.S. Government policy opposing prostitution and sex trafficking, the Department of Health and Human Services has issued a proposed rule 

that would substantially undermine that law and policy. 

It would create loopholes to allow not only affiliation, but shared 

facilities, staff, legal status, and bank accounts, as determined on 

a case-by-case basis between PEPFAR funding entities and entities 

that support prostitution and sex trafficking. 

5

As the prime author of the Trafficking Victims Protection Act of 

2000, 2003, and 2005, I find this unconscionable. 

It would also significantly reduce the assurance that USAID is 

supposed to have that a PEPFAR-funded organization is in compliance with the relevant provisions of the PEPFAR legislation. 

Unfortunately, HHS has not yet posted, on the official regulations Web site, the comments that I have submitted strenuously 

opposing this proposed rule. And without objection, Mr. Chairman, 

I would ask that we make my comments a part of the record. 

Mr. PAYNE. Without objection. 

[The prepared statement of Mr. Payne follows:]

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Mr. SMITH. I appreciate that. My office is attempting to correct 

this omission, and I invite those concerned about the negative impacts of prostitution and sex trafficking in general, with respect to 

HIV prevention in particular, to read it. And we will have it at the 

desk, on the left, today. 

The HHS proposed rule is unacceptable, and should be rejected. 

If the proposed rule is promulgated, I can guarantee you this: I will 

leave no stone unturned in fighting it. 

I must also express my grave reservations with respect to certain 

aspects of the President’s Global Health Initiative, which is otherwise an outstanding initiative. 

When the reauthorization of PEPFAR was being debated in 2008, 

references to integrating and providing explicit funding authorization for reproductive health in relation to HIV programs in initial 

drafts were rejected. The term does not appear in the final legislation. 

However, the new GHI emphasizes the integration of HIV/AIDS 

programming with family planning, as well as various health programs. This is being undertaken—and this is the important point—

undertaken in the context of a family planning program due to 

President Obama’s recision of the Mexico City policy that now includes foreign non-government organizations that provide and support and seek the expansion of abortion. 

When one considers that this involves over $715 million in family 

planning funding alone in the 2011 proposed budget, the ability of 

abortion groups to leverage this funding in relation to HIV/AIDS 

under the GHI is deeply disturbing. This integration priority in my 

opinion is wrong. 


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We are trying to prevent HIV/AIDS, not children. It is time to 

recognize that abortion is child mortality. Aborting dismembers, 

poisons, and starves to death a baby, and wounds their mothers. 

Let me remind members as well that goal number four of the 

Millennium Development Goals of the U.N. calls on each country 

to reduce child mortality, while at the same time pro-abortion activists lobby for an increase in access to abortion. 

It is bewildering, to me, how anyone can fail to understand that 

abortion is, by definition, child mortality. Abortion destroys children. 

Let me also point out that at least 102 studies show a significant 

psychological harm, major depression, and elevated suicide risk to 

women who abort. At least 28 studies, including three in 2009, 

show that abortion increases the risk of breast cancer by some 30 

percent to 40 percent or more; yet the abortion industry has largely 

succeeded in suppressing these facts. 

Breast cancer in Africa, in many parts of Africa, is a death sentence. So-called safe abortion also inflicts other deleterious effects 

on women, including hemorrhage, infection, perforation of the uterus, and sterility. 

A woman from my own state of New Jersey recently died from 

a legal abortion, leaving behind four children. At least 113 studies 

show a significant association between abortion and premature 

births. That is so under-focused upon, it is appalling. 

One example by Shah and Zao show that a 36 percent increased 

risk for preterm birth after one abortion, and a staggering 93 percent increased risk after two. And what does this mean for her children? Preterm birth is the leading cause of infant mortality in the 

industrialized world, after congenital abnormalities. 

Preterm infants have a greater risk of suffering from chronic 

lung disease, sensory deficits, cerebral palsy, cognitive impairments, and behavioral problems. Low birth weight is similarly associated with neonatal mortality and morbidity. Those facts are so 

under-reported upon, and I invite the press to look at those studies, 

and Members of Congress and members of our panel. Because we 

have, in Africa and elsewhere, as we have seen in the United 

States, designated or imposed on subsequent children born to 

women who abort a significant risk factor for a disability because 

of prematurity and low birth weight. 

So Mr. Chairman, the future of PEPFAR, and particularly in the 

context of the Global Health Initiative, has many, many challenges. 

And I look forward to exploring them with you. We have a consensus on PEPFAR. We have a consensus on so many aspects of 

global health, hopefully it does not get undermined by this emphasis on child mortality called abortion. 

Mr. PAYNE. Thank you very much. At this time we will, I am 

going to condense the biographical information I have before me. 

Normally I would go through much of the outstanding achievements, but I will, because of time, cut them short. 

I would like to introduce Dr. Peter Mugyenyi, who is the director 

and founder of the Joint Clinical Research Center in Kampala, 

Uganda, where he has served since 1992. In that role he leads the 

largest treatment initiative in Africa, funded through the U.S. 

President’s Emergency Plan for AIDS Relief (PEPFAR). He cerVerDate 0ct 09 2002 14:52 Aug 14, 2010 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 F:\WORK\AGH\031110\55398 HFA PsN: SHIRL
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tainly has collaborated with World Health Organization, National 

Institute of Health; has written books, including Genocide by Denial, and has a very outstanding resume. 

Next we will hear from Dr. Joanne Carter. She is executive director of the Educational Fund at RESULTS. She also serves as the 

board representative at the Global Fund to Fight AIDS, TB, and 

Malaria. Dr. Carter has worked with many of the world organizations, also. She is really one of the top advocates and does a tremendous amount of communicating throughout the world regarding 

the issue, and is a founding board member of the Global Acts for 

Children. 

Ms. Debra Messing is, of course, known for her role as Grace 

Adler, NBC’s Emmy-Award-winning comedy series, Will and Grace. 

She won the 2003 Emmy Award, has earned a total of seven Golden Globe nominations. She is currently the Global AIDS Ambassador for Population Services International, and has done much 

travel, recently to Uganda, and does a fantastic job in advocacy. 

Finally, we have Dr. Norman Hearst, who is a professor of family 

and community medicine and epidemiology and biostatistics at the 

University of California, San Francisco. He has published many articles—over 70. Dr. Hearst has done a tremendous amount of research, and is one of the most respected professors in our nation. 

With that, we will start with Dr. Mugyenyi. We will have your 

testimony. Thank you. 

STATEMENT OF PETER MUGYENYI, M.D., DIRECTOR AND 

FOUNDER, JOINT CLINICAL RESEARCH CENTER 

Dr. MUGYENYI. Thank you, Chairman Payne and Ranking Member Smith, for giving me the opportunity to address this meeting. 

PEPFAR has saved millions of lives in Africa. It started at a time 

when the AIDS crisis in sub-Saharan African had reached a catastrophic stage, because timely action was not taken, and the African countries were too overwhelmed by the sheer magnitude of the 

disaster. 

Before PEPFAR, less than 100,000 in Africa had access to lifesaving anti-retroviral drugs, and millions were dying from what 

had become a preventable death in rich countries. 

Today there are 4 million people on ARV treatment in low- and 

middle-income countries. These people, and their mothers, husbands, wives, and children, got a chance to live, more than half of 

whom have benefitted from the U.S. Government’s contributions, 

PEPFAR and Global Front. 

Beyond treatment, support for current prevention efforts has 

helped ease the carnage that I and my fellow healthcare providers 

used to witness on a daily basis. 

Recently, recent evidence has shown that HIV programs, where 

they have reached community-wide coverage, have been among the 

most effective interventions, having impact well beyond the AIDS 

epidemic. 

Studies in Uganda have shown the increase in services for 

HIV/AIDS was accompanied by reduction in non-HIV infant mortality of 83 percent, as parents not only lived, but thrived. The 

DART study, which I co-chaired, found a 75 percent reduction in 

malaria associated with anti-retroviral therapy. 

12

These programs have also strengthened our health systems beyond addressing HIV/AIDS. For instance, PEPFAR assisted my institution to build the seven laboratories that support nearly all of 

the public clinics, and trained several thousand healthcare providers now providing crucial services to both the public and private 

sectors in Uganda. 

This success has been coupled with re-excitement and new evidence that reaching all of those in need of ARVs could help us stop 

new infections, and beat the epidemic for good. New data from the 

Conference on Retroviruses a few weeks ago, CROI, which I attended in San Francisco, show that HIV transmission between heterosexual couples in Africa reduce by 90 percent, if the HIV-positive partner is on treatment. This gives credence to the recent modeling by the World Health Organization that shows some of the 

first good news on prevention in several years, that we could truly 

end the AIDS crisis within a generation. 

Today, however, the crisis threatens to reverse. Today, however, 

the funding crisis threatens to reverse these highly positive 

changes, and we could miss the opportunity to defeat the epidemic. 

AIDS in much of Africa is still an emergency. It continues to be 

the biggest killer of women of reproductive age. In Uganda we have 

come very far, but we are less than halfway there. 

Unfortunately, over the last 2 years PEPFAR funding has 

flatlined. New PEPFAR contract awards emphasize treatment for 

only those already on it, and only very limited slots for new patients. 

Currently my institution, which pioneered anti-retroviral therapy 

in Africa and treats the largest proportion of AIDS patients in 

Uganda, is not taking all new patients, due to lack of funding. We 

are forced to turn away desperate patients daily, often 15 to 20. 

And most of those who come to us would have been turned away 

from a number of other clinics. 

When I say new, it is important to note that most of these are 

not truly new. Thousands of Ugandans, and millions throughout 

Africa, heard the message from PEPFAR that knowing the HIV 

status was important to protect yourself and others, and that treatment would be available to those who required it. 

Even though we have put thousands of patients on PEPFAR-supported care today, my program and numerous others across the 

country cannot deliver on the promise of treatment. I have witnessed many desperate patients unable to access therapy, including 

pregnant women, resorting to desperate and dangerous measures, 

including sharing out drugs with their family members, ignoring 

the good counseling advice they receive advising against this dangerous practice. 

Recently, an HIV-infection woman, who was breastfeeding her 

HIV-negative child because she could not afford formula milk, came 

to our clinic, having been turned away from other clinics in Kampal 

because they had no slots. She knew that every day she breastfed 

her baby without being on treatment greatly increased the chances 

of her child getting infected, but she had no alternative. 

We, out at JCRC in Uganda, led the ARV-resistant testing studies, which found that treatment interruption, including sharing of 

drugs, which is becoming increasingly widespread, result in drug 

13

resistance. This will result in large numbers of patients failing on 

simpler and low-cost first-line drugs, and needing more expensive 

and more sophisticated second-line therapy. 

We must end the forced dichotomy between the prevention and 

treatment. If we choose one over the other, we will fail. We must 

invest more strenuously in treatment, while also scaling up prevention programs, including male circumcision, combination prevention and services targeting high-risk groups. 

Let us also not forget that strengthening the health system and 

getting AIDS treatment to those who need it are not contradictory 

goals. We know from our experience in the 1990s that if treatment 

isn’t there, people will not come to the health centers, and doctors 

will not stay. 

We know from our long experience that it is virtually impossible 

to have successful public health sector and AIDS programs, where 

some people get therapy and others in dire needs don’t. 

The news of President Obama’s new Global Health Initiative was 

received in Africa with great appreciation and enthusiasm. However, to ensure maximum health benefits, we must build in past 

successes, and ensure sufficient new money is available for successful integration of serious health issues. Otherwise we risk going 

back to the failed approaches of the 1990s that do not prioritize 

provision of lifesaving drugs. 

In conclusion, Mr. Chairman, allow me to refer to repeated commitments by United States universal access AIDS services in U.N. 

declarations, which caused great excitement and expectation in Africa. 

U.S., as the world’s friend, came to the rescue of Africa at the 

time of our greatest need. It is our hope that current efforts can 

be strengthened, so that one day we can achieve our shared goal 

of a world free of AIDS. 

Thank you again, Mr. Chairman, for this opportunity, and the 

American people for their compassion and generosity. Thank you. 

[The prepared statement of Dr. Mugyenyi follows:]

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Mr. PAYNE. Thank you very much. Thank you. 

Dr. Carter. 

STATEMENT OF JOANNE CARTER, D.V.M., EXECUTIVE DIRECTOR, EDUCATIONAL FUND, RESULTS (ALSO BOARD MEMBER 

OF THE GLOBAL FUND TO FIGHT AIDS, TB AND MALARIA) 

Ms. CARTER. Chairman Payne and Ranking Member Smith, 

thank you so much for inviting me to discuss the opportunities and 

challenges ahead for U.S. investments in HIV/AIDS program. 

The House Foreign Affairs Committee, and particularly the members of this subcommittee, have been instrumental in crafting and 

supporting our U.S. AIDS response, with results that were almost 

unimaginable only a few short years ago. Both you and Dr. 

Mugyenyi referred especially to the massive treatment scale-up. 

And despite the clear bipartisan mandate of the Lantos Hyde Act, which, as you said, authorized $48 billion over 5 years, both 

to build on what has been achieved and to ramp up the response, 

there is unfortunately a significant gap between the vision expressed in that bill and its realization. 

So I would like to briefly review the funding situation we currently face, and then turn to some important opportunities to increase the impact of our response. 

The administration’s Global Health Initiative calls for a more integrated, comprehensive AIDS and health response. It is a welcome 

intent, but it is only going to work if it is adequately funded. 

The President’s Fiscal Year 2011 budget request essentially flat 

funds for our global AIDS programs, with just a 2 percent increase 

in bilateral AIDS funding, several billion short of what would have 

been needed to reach the Lantos Hyde authorization levels. And 

the budget actually proposes a $50 million cut to the Global Fund 

to fight AIDS, TB, and malaria, and just a minuscule $5 million 

increase for bilateral TB, even though TB is the leading killer of 

people with AIDS. 

And as Dr. Mugyenyi has pointed out, flat funding actually 

means cuts to lifesaving services at the very moment when we built 

the capacity and the demand to get to the finish line, and at the 

very moment when the global economic crisis has profoundly exacerbated needs in Africa. 

I would like to highlight just three opportunities to fundamentally alter the course of the HIV/AIDS epidemic in the coming year. 

The first, again building on what Dr. Mugyenyi said, is to continue to scale up treatment, not just as a medical and a moral imperative, but actually as a public health strategy for reducing 

transmission of HIV. There is a growing body of evidence that 

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And Congressman Smith, you raised the issue of, in a sense, the 

treatment mortgage, and the growing cost. But there is also both 

evidence and really exciting modeling that shows that if we are aggressive now on universal access to testing and early treatment, 

within not a very long time you actually break the back of the epidemic, and you start to see the curve going down. It just requires 

aggressive investment up front to make that happen. And we 

would be glad to share some more of that data with you. 

A second critical lifesaving opportunity is tackling tuberculosis. 

And both of you have really been leaders on this issue. It is the 

leading killer of people with AIDS. And as you know, an HIV-positive person who gets sick with TB is dead within a few weeks. 

Yet fewer than 4 percent of people with HIV/AIDS are screened 

for TB. This is the low-hanging fruit when it comes to saving lives, 

and we have yet to seize it. And people are now quite literally living with HIV because of ARVs and dying of TB. 

In just a few weeks the WHO is going to also reveal new data 

around the growing epidemic of drug-resistant TB. And despite successful pilot efforts, PEPFAR is still failing to take TB/HIV efforts 

to scale, and is essentially flatlining TB/HIV funding in Fiscal Year 

2011. 

And the Global Health Initiative, as I said, proposes just a $5 

million increase; but, perhaps more worrisome, it actually proposes 

targets for TB treatment scale-up that are much lower than actually what was in the Lantos Hyde Act. 

We actually know what to do about TB/HIV. We are just not 

doing it. 

And finally, I want to say we just have a tremendous opportunity 

to accelerate our global health efforts by increasing our support for 

the Global Fund to fight AIDS, TB, and malaria. 

I am honored to serve as the Northern Civil Society Representative to the Fund Board, and I would urge all of you to read the Annual Results Report released by the Fund just this week. Because 

I believe the Fund is the most effective tool we have in fighting 

these three diseases. 

The Global Fund has supported 2.5 million people on antiretroviral treatment, 6 million treatments for TB, and the distribution of 104 million bed nets to prevent malaria. These efforts have 

saved an estimated 4.9 million lives through investments in 144 

countries. 

I would just say that the success of the Fund is not just what 

has been achieved, but how it has been achieved; through an innovative, performance-based, transparent, multi-stakeholder process. 

One example. By focusing on value for money on all levels, the 

Fund has identified $1 billion in efficiency savings. And its impact 

has gone well beyond AIDS, TB, and malaria. 

Ethiopia has trained and deployed over 30,000 community health 

workers through Global Fun investments, with not only an astounding increase in AIDS treatment, but also rapid improvements 

in child and maternal health indicators, like measles vaccinations 

and births attended by health professionals. 

Civil society participation, as you know, is a prerequisite for the 

Fund, and 36 percent of grants are distributed to non-governmental organizations. 

21

And just on the funding issue. Importantly, the U.S. funding for 

the Global Fund has traditionally been matched two-to-one by 

other donors. Two-thousand and ten is going to be a critical year 

in determining the future of the Global Fund. Other donor countries will be making 3-year funding commitments as a part of the 

Global Fund’s replenishment, and the President’s proposed $50 

million cut not only underfunds this hugely effective mechanism, 

but actually fails to exert any leverage on other donors. 

And just to, in conclusion, what is at stake. By 2015 we could 

virtually eliminate maternal-to-child transmission of HIV, eliminate malaria deaths in many endemic countries, and contain the 

spread of multi-drug-resistant TB. These are things we didn’t 

dream were possible even a few years ago. And the Global Fund 

estimates that to maximize its impact will require about $20 billion 

from all sources for quality programs over the next 3 years. And 

a U.S. down payment would be about $1.75 billion for 2011. 

If I can just end by saying sometimes it is difficult to articulate 

the profound impact our investments have had. But I wanted to 

share a story from my friend, Winston Zulu, who is the first person 

to go public on his HIV status in Zambia, and who lost all four of 

his brothers to TB. 

When I asked Winston the impact of the Global Fund and 

PEPFAR, he said something that I first didn’t understand. He said 

now when I visit a village in Zambia, and I don’t see a friend or 

a family member, I ask where they are. He said 10 years ago in 

Zambia, if you went to a village and you didn’t see someone, you 

never asked, because you assumed they died of AIDS. 

So just to say that our investments have done more than deliver 

drugs and diagnostics, this is nothing short of a transformation of 

despair into hope in an astonishingly short period. 

So I just am grateful for both of your leadership on this, and the 

leadership of this committee. We have made remarkable progress, 

and we can’t stop now. And I look forward to your questions. 

Thank you. 

[The prepared statement of Ms. Carter follows:]

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Mr. PAYNE. Thank you very much. We will now hear from Ms. 

Messing, who I mentioned was in Uganda recently, but I was 

thinking about Dr. Mugyenyi. It was Zimbabwe, I think, for your 

recent travels. I stand corrected. Thank you. 

STATEMENT OF MS. DEBRA MESSING, GLOBAL AIDS 

AMBASSADOR, POPULATION SERVICES INTERNATIONAL 

Ms. MESSING. Good afternoon, Mr. Chairman and members of 

the subcommittee. I am honored to join you today, representing 

PSI, a leading global health organization with programs targeting 

HIV in 55 countries, as well as programs in malaria, reproductive 

health, and child survival. 

I thank Chairman Donald Payne, Ranking Member Chris Smith, 

the distinguished members of the subcommittee and their staff 

members for organizing today’s hearing. 

In 1993, at the age of 41, Paul Walker, my dear friend and acting 

teacher, died of AIDS-related complications. Paul’s loss was devastating. After Paul’s death I was moved to learn more about the 

epidemic. 

Three months ago I traveled to Zimbabwe with my colleagues 

from PSI, and with staff from UNAIDS, to learn more about the 

HIV pandemic in sub-Saharan Africa. What I saw in Zimbabwe 

was that the investment and strong support from PEPFAR, the 

Global Fund to Fight AIDS, Tuberculosis, and Malaria, and other 

donors, as well as the Zimbabwean Government, is paying off in 

dramatic ways. 

For example, Zimbabwe has experienced a reduction in HIV 

prevalence among adults from 29 percent in 1999 to 14 percent in 

2009. But it also became heartbreakingly clear to me that resources still fall short of what is needed to reach everyone at risk 

for HIV. 

I would like to tell you today about two prevention tools that 

could make a difference, if there is continued investment. Male circumcision and HIV testing and counseling. 

First, voluntary adult male circumcision. There is now strong 

evidence, recognized by UNAIDS and the World Health Organization, that male circumcision reduces the risk of heterosexually acquired HIV infection in men by about 60 percent. Yet only about 

one in 10 Zimbabwean adult men are circumcised. 

P.S.I and its partners run circumcision clinics in Zimbabwe and 

other countries, with support from PEPFAR and other donors. 

I was invited to observe the procedure, which is free to the client, 

completely voluntary, and, according to the young man I spoke 

with who underwent the procedure, painless. The cost of the procedure at that clinic, including followup care and counseling, is about 

$40. 

Even with no demand creation, the clinic I visited serves upwards of 35 clients per day. It is estimated that if male circumcision is scaled up to reach 80 percent of adult and newborn males 

in Zimbabwe by 2015, it could avert almost 750,000 adult HIV infections. That equals 40 percent of all new HIV infections that 

would have occurred otherwise without the intervention. And it 

could yield total net savings of $3.8 billion between 2009 and 2025. 

29

Many of the clinic’s patients learn about male circumcision when 

they receive HIV counseling and testing at PSI’s New Start Centers, and through its mobile outreach teams in Zimbabwe. Testing 

and counseling is the next area I would like to discuss. 

An estimated 72 percent of Zimbabweans with HIV are unaware 

that they are infected. To better understand the HIV counseling 

and testing process, I was tested for HIV at a PSI New Start Center in Harare that is funded by PEPFAR, the Global Fund, and the 

British Government. 

Despite the fact that I was confident of the results, I still felt 

anxious. In a pre-testing session, a counsellor talked to me and 10 

other people about how HIV is transmitted, how to reduce risk, 

what happens if you test negative, what happens if you test positive; all bases were covered. And I felt my anxiety lessen, and I 

could see the same thing happening for those around me. Knowledge is power. 

A lab technician gave me the confidential test, a tiny pinprick to 

the finger. In a private room, a trained counsellor gave me my results after 15 or 20 minutes, and I felt a great sense of relief. I was 

counseled on staying negative. 

Had I tested positive, I would have been counseled on what that 

means. And I would have been referred to a post-test center, where 

I would receive additional counseling and referral services for antiretroviral treatments. 

Thirty-five thousand Zimbabweans go through this HIV counseling and testing experience every month, as I did, emerging with 

a greater awareness of measures they can take to protect themselves and others. 

I saw firsthand that the U.S. Government’s investment in 

HIV/AIDS is working. But although we have and utilize effective 

HIV prevention tools and strategies, like male circumcision and 

HIV counseling and testing, data from UNAIDS indicates that the 

epidemic continues to grow. Every day, 7,400 people become newly 

infected with HIV worldwide, and there are five new HIV infections 

for every two people put on treatment. 

In closing, I urge your ongoing robust support for PEPFAR and 

the Global Fund so that we can halt the spread of HIV, and comprehensively expand access to HIV prevention, care, and treatment. 

I am so grateful for the opportunity to brief you, Mr. Chairman, 

honorable members and colleagues. Thank you so much. 

[The prepared statement of Ms. Messing follows:]

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Mr. PAYNE. Thank you. Dr. Hearst. 

STATEMENT OF NORMAN HEARST, M.D., PROFESSOR OF FAMILY AND COMMUNITY MEDICINE AND OF EPIDEMIOLOGY 

AND BIOSTATISTICS, DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO 

Dr. HEARST. Thank you. Good morning. That is a tough act to 

follow. 

It is an honor to be here. As someone who has worked with AIDS 

epidemiology and prevention for 25 years, I greatly appreciate this 

opportunity to share my thoughts about the future of PEPFAR. 

In my field, at least, I know that Congress can work together in 

a constructive and bipartisan way. PEPFAR has made a tremendous difference for many individuals and countries, and has done 

great things for the reputation of the United States in large parts 

of the world. Thank you. 

Nevertheless, PEPFAR today is at a crossroads, and faces new 

and difficult challenges. Some of these are results of PEPFAR’s 

success; others are inevitable consequences of the mathematics of 

the AIDS epidemic. 

The last time I testified here was before the full committee, during the PEPFAR reauthorization hearings. The most contentious 

issue then was earmarks for prevention: Whether to require that 

a proportion of prevention funds go toward reducing the behaviors 

that spread HIV, as opposed to things like condoms and testing. 

At that time Tom Lantos, who had been my representative and 

for whom I voted many times, who was chairing the committee, at 

that time the main emphasis of my testimony was the solid scientific evidence behind the A and B of the ABC strategy for AIDS 

prevention: That is, abstinence, and be faithful, and to make clear 

that it wasn’t just some sort of plot by the religious right. 

I am happy to say that Congress came up with a reasonable compromise on this issue. While ending rigid earmarks of spending for 

A and B, you required that PEPFAR programs in countries with 

a generalized AIDS epidemic provide a justification if they spend 

less than half of their prevention budget on A and B. Such justifications have now been submitted by some countries, and for the 

most part, they appear reasonable. The system is working. 

I don’t know if anyone is pressuring you to revisit this compromise. If they are, I don’t know what the problem is that they 

are trying to fix. 

But today I am concerned that PEPFAR’s prevention efforts soon 

will be under an even greater threat than unfortunate ideological 

battles about how much to spend on promoting condoms versus encouraging people to stick to a single partner. 

The threat now is that prevention money may be syphoned off 

for treatment. As I said the last time I testified, we cannot treat 

our way out of this epidemic. What has happened since? PEPFAR 

is treating more people. But the number of people entering treatment is far less than the number of people getting infected, by 

somewhere between a two-to-one and five-to-one margin, depending 

whose numbers you believe. 

34

So despite all our efforts to rapidly scale up treatment, we are 

falling farther and farther behind. Funding for treatment cannot 

keep growing exponentially, and we now have many people on 

treatment whose virus is developing resistance to first-line drugs. 

This means they will require more and more expensive alternate 

drugs. 

Remember that we are not curing anyone. The people that 

PEPFAR treats have a lifetime entitlement to whatever drugs they 

need, unless we want to cut them off and let them die. So despite 

all our efforts to enhance efficiency and decrease unit costs, it is 

going to be increasingly expensive just to maintain the people we 

have on treatment, let alone to keep adding more. 

This is ironic, because we have worked so hard to encourage people to come in for testing and treatment. We have labored to create 

the demand for anti-retroviral treatment, and now we will inevitably find ourselves unable to satisfy that demand. 

Instead of being good guys for keeping millions of people alive, 

we seem to have set things up so that we will now become bad 

guys for turning people away. 

What we should be learning from the current situation is the 

paramount importance of prevention. What I am afraid will happen 

instead is tremendous pressure to divert the minority of PEPFAR 

funds going for prevention to treatment, so as to briefly postpone 

the day of reckoning, when we will have to admit we can’t treat 

everyone. This would be a terrible mistake. 

There are people who will try to convince you that treatment 

somehow is prevention. They will tell you that prevention requires 

people to get tested, and that no one will get tested unless treatment is available. They will come up with complex mathematical 

models based on unrealistic assumptions to justify their assertions. 

Don’t be fooled. Prevention is prevention; treatment is treatment. 

Any overlap is mostly wishful thinking in the African context. 

People promoting treatment as prevention in Africa ignore how 

HIV spreads in generalized epidemics. A large proportion of transmission takes place in early infection, when people’s viral loads and 

infectiousness are highest, through networks of interlocking sexual 

partnerships, before people would even test positive, let alone enter 

treatment. How can treatment possibly stop that? 

Today we have many well-meaning people who want desperately 

to believe that treatment will work for prevention, but they have 

very little real evidence to show that it does. Instead, they offer 

theoretical models about how maybe it might work, and pretend 

this is evidence. 

The fact is that even in places like my hometown of San Francisco, where we have ideal conditions for so-called treatment as 

prevention, the evidence for whether it works is far weaker than 

people would have you believe. Yes, treatment can lower some people’s viral load and make them less infectious, at least temporarily. 

But any benefit from this is probably overwhelmed by the negative 

effects of treatment on prevention. Once the general public knows 

that effective treatment is available, they worry less about AIDS 

and become riskier in their sexual behavior. We see this all over 

the world. My own research has shown this in places like Uganda 

and Brazil. 

35

What does work for prevention? Look at Uganda, the African 

country where I have worked the most. In the late 1980s and early 

1990s, Uganda was Africa’s greatest prevention success story. This 

was before HIV testing was available, long before treatment was 

available, and even before many condoms were coming into the 

country. 

But Uganda was able to cut its HIV infection rates by two thirds, 

simply by convincing people, on the average, to reduce their number of sexual partners. This was done with almost no donor funding. 

Now fast-forward to 2010. What is happening in Uganda? Most 

Ugandans have forgotten about reducing their number of partners, 

and instead internalize the foreign-donor message that prevention 

is really about condoms and getting tested. Furthermore, Ugandans 

who believe that effective AIDS treatment is available are now the 

very ones most likely to have multiple sexual partners. And rates 

of HIV are going back up again. 

I am not saying that treating people with AIDS is bad; I think 

it is great. If you can double funding for treatment in places like 

Uganda, I applaud you. But if you can’t, PEPFAR needs to squarely face the reality of limits on how much treatment can be provided, and certainly not to raid the prevention budget to treat a 

few more people. Even if you double or triple funding, you will just 

have to face the same reality a year or 2 later. 

Facing reality is not easy. It means telling people in governments 

that we cannot bankroll unlimited treatment. We need to say, in 

a clear, unapologetic way, because we have nothing to apologize for, 

how much we can contribute. 

In Uganda and other African countries, treatment facilities are 

now turning away patients because the spots funded by PEPFAR 

and other donors are full. There was a recent cover story about this 

in the Wall Street Journal. It didn’t help that Dr. Goosby was 

quoted as saying that PEPFAR will turn away no one who needs 

treatment. He may have been quoted out of context, but such statements will only breed resentment when it becomes impossible for 

us to make good on those words. 

We are now faced with flat funding to deal with an overwhelming and growing backlog of need. When the supply of treatment no longer meets demand, we will need to be especially vigilant about how scarce lifesaving treatment is allocated. Remember 

that many PEPFAR priority countries have tremendous disparities 

between rich and poor, between men and women, between the capitol city and rural areas. Many have poorly functioning governments and serious problems with corruption. 

We will need mechanisms to ensure that treatment funded by 

PEPFAR goes equitably to those who need it most, even in countries where nothing else is distributed equitably. 

PEPFAR already pays a great deal of attention to transparent 

and corruption-free financial management. But this will be a whole 

other challenge that will require specific monitoring. 

If any of my comments seem overly critical, I apologize. PEPFAR 

is a great program that has done great things in a short time, and 

about which all Americans should feel proud. But it now must grow 

36

up and recognize that it is not really an emergency program at all, 

and that we are in this for the long haul. 

We must be exceedingly wary of perceived open-ended promises 

that we cannot keep. We must base our efforts on reality, not wishful thinking. We must reject those who tell us that treatment is 

prevention, based on platitudes and unrealistic models. We must be 

clear and unapologetic about what we can and cannot do. And 

above all, we must not abandon the fight just because there are no 

easy solutions. 

Thank you. 

[The prepared statement of Dr. Hearst follows:]

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Mr. PAYNE. Thank you very much. Unfortunately, there is a vote 

that has been called, so I will divide the time between three of us 

here, maybe about 4 minutes each. And because there is a series 

of six votes, I certainly cannot ask the panel to remain for that long 

a period of time. 

So let me begin by asking Dr. Mugyenyi, how would you evaluate, overall, the situation in Uganda? As we have heard early on, 

Uganda was discussed because of the tremendous problem. Then 

we saw the fact that Uganda really stepped up and had really aggressive programs, and we saw the increase level off, and even 

start to decline. Now they say there is, once again, a gradual increase. 

How would you characterize Uganda at the current time, maybe 

in a minute or two? And what you would suggest that we do to assist you, if we see things are in a negative mode? 

Dr. MUGYENYI. Thank you, Mr. Chairman. The situation in 

Uganda at the moment is quite worrying, for the simple reason 

that we are turning away patients. No provisions have been made, 

for example, for a pregnant woman. These pregnant women are 

turning up daily in various places. And the recent example is an 

HIV-positive pregnant woman who could not get treatment from 

several clinics because she is a new patient. We are not taking on 

new patients because the slots are few. 

Now, the testing that people who came for testing, Mr. Chairman, when we first started, and offered treatment, was so great 

that our clinics were swamped with people who wanted to know 

the actual status and the understanding that treatment would be 

available to them. 

Now, since the slots for treatment declined, our clinics can’t go 

a day without anybody coming to offer testing. It is abundantly 

clear to us who are living on the ground in Uganda that treatment 

has been a great incentive for people to come for preventive services. 

Mr. PAYNE. Thank you, thank you very much. What we might do 

is that we decided that we will ask questions, and then, although 

we will have to leave, we would like for the questions to be answered in the time that we will allow the staff to listen to the answers, so it becomes a part of the record. And that way we can accommodate everyone. 

So I wonder, Ms. Messing, just a question. You became interested 

and involved in this area because of a person that you knew; and 

this issue, therefore, got your attention. 

I think that we need many, all levels of people, all walks of life 

interested in trying to work on education. And I just wonder if you 

have any suggestions on how we can get other people of your stature. We find that when we have people that have a lot of notoriety 

taking on an issue, it helps. And so if you have any idea of how 

we can, you know, get more associates of yours to take an interest 

like you have—that would be interesting to hear. 

And Dr. Carter, you know, in both the recent 5-year strategic 

plans for PEPFAR and the Global Health Initiative consultation 

documents, the U.S. Government states plans to better engage and 

leverage its relationship with multi-lateral partners, such as U.N. 

System and the Global Fund as a goal. 

42

How would you specifically encourage the U.S. Government to 

enhance those relationships? And how could the U.S. Government 

better harmonize its efforts with its multi-lateral partners? 

And just finally, Dr. Hearst, maybe you could give us a short 

synopsis of, once again, the priorities you would see, since you have 

indicated that we can’t treat our way out. Too much is going for 

treatment and prevention efforts are lacking. Some ideas of how 

you would deal with that. 

And I will yield now to the gentleman, Mr. Smith. 

Mr. SMITH. Thank you, Mr. Chairman. I have a number of questions, but I will narrow it to four, and look forward to reading or 

hearing your answers upon our return. 

I was at the U.N. Forum last year when Mr. Sarkozy and others 

made this real push for more mother-to-child transmission funding. 

And I wonder if all of you, or some of you, might want to comment 

on how inadequate or adequate our current funding level is in 

PEPFAR for mother-to-child transmission. 

Secondly, and Dr. Carter, this might be more a focus for you; 

when the Global Fund was first launched, all of us thought this is 

an idea whose time has come. But it was bypassing faith-based organizations almost systematically. The CCMs that have been established very easily can sidestep a faith-based hospital infrastructure. 

We know that in Africa, between 30 percent to 70 percent of the 

healthcare is under some religious auspices. It is a turnkey operation just waiting to be further utilized. I actually offered the Conscience Amendment, which passed only by one vote the first time 

in 2003, when we did the reauthorization when Tom Lantos was 

chairman. There was a broad consensus, and we had an excellent, 

solid conscience clause, so that certain faith-based groups that 

don’t want to do certain kinds of prevention activities would not be 

precluded funding. 

What is the faith-based focus—we have met with Dr. Christoph 

Benn on a number of occasions to try to raise this issue. Please 

give us an update on that. 

Thirdly, very quick, Dr. Hearst, the Lancet had pointed out that 

the priority for adults should be B (be faithful), limiting one’s partners; the priority for young people should be A (abstinence), or not 

starting sexual activity too soon. And that condoms, and you pointed out in some of your writings, and you had done a UNAIDS technical review, you said that when we look for evidence of public 

health impact for condoms in generalized epidemics, to our surprise, we couldn’t find any. And you differentiated between generalized epidemics and a more focused one, a concentrated one. 

And finally, the IG’s report—Dr. Carter, you might want to speak 

to this—some 48 percent of its recommendations had been—I know 

we are running out of time—had been not fully implemented by the 

time of the OIG’s review. Your view as to how the Office of Inspector General is working. Because, you know, from an accountability 

point of view, a dollar wasted means a lost life. 

And we want, as we ramp up additional funding, we want the 

best impact possible, so good utilization of those dollars is important. Thank you. 

Mr. PAYNE. Thank you. Mr. Miller. 

43

Mr. MILLER. Thank you. Dr. Carter, I know that you are familiar 

with the slum legislation that I introduced. And at risk of sounding 

single-minded, I think all of you are familiar with the number of 

studies and pilot programs that have documented a connection between secure, adequate housing and health outcomes. Certainly 

communicable diseases in particular, including HIV/AIDS, but also 

other chronic non-communicable diseases. 

But there doesn’t seem to be much of a policy. And it appears 

not to just be a correlation that both inadequate and unsecure, insecure housing occurs in very impoverished societies; but there 

seems to be a causal connection. 

Do you see adequate housing programs as a health intervention 

for HIV/AIDS or other health conditions, for the prevention and 

treatment of HIV/AIDS? And do you think that there should be 

more of a policy focus on that as an approach to HIV/AIDS prevention and treatment? 

Mr. PAYNE. Well, thank you very much. What I will do at this 

time, first of all, I would like to put into the record that Mrs. 

Dubula, who is the General Secretary of Treatment Act Campaign 

in South Africa, had originally planned to testify before the subcommittee today, but unexpectedly fell ill. 

Therefore, I will ask unanimous consent that Mrs. Dubula’s testimony be made part of the record. Hearing no objection, so ordered. 

Also, before members will have 5 legislative days to revisit and 

extend, revise and extend their remarks. And with no objection, we 

will now ask the panelists if you would be kind enough to answer 

the questions that were asked to you, in the order. 

And with that, we must leave to vote. Once again, let me thank 

all of you for coming, and we apologize, but we can’t control what 

happens on the Floor. Thank you very much. 

And just technically, for the record, this hearing will continue for 

the purpose of getting answers to questions asked by the members. 

It therefore makes you official. Thank you. 

[Recess.] 

Mr. PAYNE. Well, it has been indicated that we will be unable to 

hear your questions, according to a ruling here, and that we may 

ask you to give us your answers in writing—and that the meeting 

will—we are trying to see whether there is a non-voting Member 

of Congress. We do have Mr. Eni Faleomavaega, who is chair of the 

Asia, the Pacific and the Global Environment Subcommittee, who 

is a non-voting member on this particular subject. And if he is 

available, then he could sit. 

Why don’t we start responding? I guess Dr. Mugyenyi, would you 

like to begin your answer? 

Dr. MUGYENYI. Yes. Mr. Chairman, I was very concerned with 

Dr. Hearst’s testimony, because the data that we are accruing in 

Uganda, and especially from my institution, which is closely involved with the HIV/AIDS since the early 1990s, clearly show that 

treatment is associated with strong incentives for prevention. 

So my submission today is that data which we have shows that 

that is what we have, right from our clinic, and the data that we 

have recently published. We followed up, we followed up 3,400 severely infected patients with AIDS. And we found among those 340 

babies were born. Not a single one among those was infected with 

44

HIV. And secondly, not any of the babies have been infected 

through breastfeeding. 

On maternal and child health, if we can provide PMTCT, we can 

prevent lots of pediatric infections. On the adults, we are finding 

that discordant couples, who are high-risk groups, perhaps the 

highest-risk groups, if you treat the infected partner, we are getting as high as a 90 percent reduction in infection. And then, very, 

very impressively, we find that if, in any clinic, you introduce treatment, people coming for testing just increase almost overnight. We 

have found opposite results in the clinics which do not have treatment. People just don’t go for testing. 

Our studies are indicating that it is people who don’t know their 

status who have no incentives to come for testing, who are contributing significantly to the continuing spread of HIV in our countries. 

I am not saying that prevention is not important. I am saying 

prevention and treatment, both of them are extremely important, 

and they need to be scaled up together. I would state quite categorically that without treatment, prevention is futile. 

Mr. PAYNE. Thank you. Dr. Carter, maybe you can respond to 

one of the questions. And Mr. Faleomavaega is on his way down, 

and then we will hear each of you answer one of them, and see if 

there are any remaining questions to be answered. Thank you. 

Ms. CARTER. Yes, thanks a lot. One question you asked was 

about the GHI’s intent to work more with multi-lateral institutions. 

And maybe I will just say a few quick comments around the Global 

Fund. I mean, just to say that given that the Global Fund is providing about two thirds of the external donor funding for tuberculosis and malaria, it is actually a key back—and a quarter of 

AIDS funding—it is a key backbone for U.S. efforts. 

And if you talk to the President’s malaria initiative folks, but 

also as far as TB, and certainly a really important partner on 

HIV/AIDS. And again, I think really complimenting each other in 

a sense that PEPFAR has certainly been more focused, but the 

Global Funding and working in 144 countries has got that breadth 

of efforts that is kind of complimenting, but also filling in many of 

the gaps that PEPFAR is not reaching. 

I think, as you are aware, PEPFAR is also providing important 

technical support and technical assistance to help in the implementation of Global Fund grants. And that is actually an important 

role. 

And I would say there is a few lessons that are being gleaned 

from the Fund with regards to value for money. Like how do we 

reduce commodity costs, how do we actually benchmark the cost of 

quality interventions, like what does it cost to deliver AIDS treatment, what does it cost to deliver prevention in certain areas. And 

benchmarking some of those in a way that I think can benefit not 

just the Global Fund, but kind of all of our initiatives, and helping 

us find efficiencies on that. 

So those are just I think some of the ways that PEPFAR can 

partner with, but also, I mean, in a very substantive way, but also 

in a kind of aid-effectiveness model with the Global Fund. And it 

is quite important. 

Mr. PAYNE. Yes. 

45

Ms. MESSING. Mr. Chairman, you asked how I could help bring 

attention to my peers in the Hollywood community, or other public 

people, so that they can help support this effort. I will commit to 

engage my peers in Hollywood. 

What I would like to say is that I think what is an even more 

powerful strategy is to involve young people in the political process; 

to build leaders among our youth. I am so glad to see so many 

young people here today. I came a little bit late to the process. 

And I would also like to say that it is, I believe that it is part 

of our DNA, as Americans, to help, regardless of where it is. That 

has been proven with our reaction to the Haiti crisis, and I think 

it is our moral imperative. 

So I think that you can get people from—I am sorry. 

[Pause.] 

Ms. MESSING. I think that people in my community like to stand 

behind things that they know work. And the efforts that the U.S. 

Government has made, the investments that they have made in 

HIV prevention have been proven to work. 

And it has been good works, so far. We just need to increase the 

funding for prevention, so that the good works can help more people. 

Mr. FALEOMAVAEGA [presiding]. I believe the question has been 

raised for all the members of the panel to respond to. And I want 

to thank Ms. Messing for her response. 

And I believe Dr. Hearst may have a comment on this question, 

as well. 

Dr. HEARST. Yes, thank you. They were kind of a series of questions thrown out, and I will try to kind of weave them together and 

address as many of them as I can. 

I was asked what I would suggest the priorities would be, and 

what we should do. Even though I am someone who has worked 

in prevention mainly, and would love to see more resources going 

to prevention, I am not here making a pitch to increase the proportion of PEPFAR funding going to prevention. I think PEPFAR 

probably has the mix about right. And there is a tremendous need 

for treatment, and I am not arguing that that should be cut back. 

All I am saying is let us not cut back prevention when we see 

this tremendous need in demand for treatment in front of us. And 

in the prevention area, my priorities would be to invest the money 

on what has worked; that is the ABC strategy. And now what is 

new in the last few years is the increasingly good evidence behind 

male circumcision, which you have just heard from Ms. Messing, as 

an effective, cost-effective intervention that actually there is a 

great deal of interest in. And we need to make sure that that is 

available to anyone who wants it, in an easy and affordable fashion. 

When I say I support the ABC approach, I support all three 

parts of it. But, as Mr. Smith was alluding to, in generalized 

epidemics it seems to be the B of the ABC that makes the most 

difference. You have got to get people to limit their number of partners, to stick to one partner, if not for a lifetime, at least one partner at a time. 

It seems to be these networks of overlapping, ongoing relationships that, if one person in there gets infected, the whole thing 

46

goes up in flames, so to speak. At least the research I have seen, 

Africans don’t have any more—the number of sexual partners they 

have in their life isn’t any higher than Americans or Europeans. 

But there seems to be, at least in some countries, more of these ongoing overlapping relationships, as opposed to the more serial monogamy we have in the U.S. I am not saying one is better than the 

other or worse than the other; it is just that the one facilitates the 

spread of HIV more. We need to break up these networks of multiple partnerships. That is what really makes the most difference. 

And which really, when you get down to it, has nothing to do 

with testing. You will keep hearing, we have got to get testing, people have got to come in for testing to do prevention. 

Testing is great. It has nothing to do with prevention. Being tested doesn’t prevent a single infection. It only prevents infection if 

it then leads to changes in behavior. 

So as Ms. Messing was describing, she comes in and tests negative; they tell her use condoms and stick to one partner. If she had 

tested positive, they would tell her use condoms and stick to one 

partner. The message is the same. You don’t need testing to do prevention. You do need testing to do treatment. 

I was asked, or we were all asked about mother-to-child transmission. Again, I think PEPFAR probably has the mix of funding 

about right. Mother-to-child transmission is a very appropriate target for our prevention efforts, because it is a moral imperative. We 

want to protect the most vulnerable, who certainly are infants. And 

it works. So it is a good place to invest our resources in that sense. 

However, I have to qualify that a little bit, as an epidemiologist 

and looking at the public health perspective, to say that as important as it is, it doesn’t really have much of any impact on the epidemic. Why? Because preventing transmission to babies is wonderful and an imperative and all that, but those babies wouldn’t be 

transmitting the virus to anybody else, at least not until they grow 

up and survive into adolescence or adulthood. So they are sort of 

an epidemiological dead end. They are very important as human 

beings, but unfortunately less important, epidemiologically speaking, because they wouldn’t transmit to others. 

I was asked about, we were all asked about housing and poverty, 

and the relation to AIDS. And I think it is very important that we 

think of, that people need housing. I think it is a crime sometimes 

that the West will spend, and us, will spend thousands of dollars 

a year so that they don’t die of AIDS, but who cares if they live 

in abject misery. And I think that is a real contradiction. 

However, in the field of HIV/AIDS, unlike tuberculosis and many 

other diseases, there is no clear relation between income, poverty, 

and HIV/AIDS. In fact, in most African countries, HIV/AIDS rates 

are actually higher among those who are relatively better off. 

So I think we need to do poverty alleviation because we need to 

do poverty alleviation, but really, we shouldn’t fool ourselves into 

thinking that is AIDS prevention. Rich people do not have fewer 

sexual partners than poor people. In fact, particularly among men, 

they tend to have more partners. And that is what spreads the epidemic; it is having multiple partners, it is not being poor. 

I think that touched on most of the questions that were asked. 

Thank you. 

47

Mr. FALEOMAVAEGA. I don’t know if a question was raised by 

members who were here previously, but just wondering, you know 

when HIV/AIDS first came about, the stigma attached to this illness was so negative, even when it touches on the gender. 

And I wanted to ask the members of the panel if America has 

gone past that. If you are associated, or if you have HIV/AIDS, not 

only isolation, but they put you as something, almost classify you 

as someone who is immoral. And I was just wondering if members 

of the panel, what is your take on what seems to be the sentiments 

of members of our society, especially here in this country. I don’t 

know how it compares to Africa. But I would be very curious. 

Ms. Messing? 

Ms. MESSING. Well, I can’t speak to the specifics of the United 

States. But what I can tell you is what I saw and experienced in 

Zimbabwe, and at the New Start clinics that are part of the U.S. 

investment. 

There is a focus on instilling hope, and empowerment to the people who have been diagnosed positive. I met with people who were 

positive, who were graduating from a long series of sessions, learning how to live positively. And I can tell you that whatever stigma 

there is—and there is a stigma there, as well—that the prevention 

efforts address that. 

And if I may, I would just like to respond to Dr. Hearst, and say 

that in my travels in Zimbabwe, I saw firsthand the PSI programs 

at work. And they target reduction of concurrent sexual partnerships. That is a, one prong in a multi-pronged attack, which includes condoms, testing, counseling, male circumcision, delaying 

sexual debut. 

I sat with a boy who was the first person to get circumcised in 

Zimbabwe, 18 years old. And he had never been sexually active 

prior to it. And he told me that through his counseling, he had determined that he was going to delay his onset of sexual activity. 

And I sat with people who had gone through the HIV testing 

process, and I sat alongside people who were counseled. And they 

told me that the information that they had gotten from the New 

Start clinic had made them change their behavior regarding sexuality. 

So to say that just condoms or just testing, it is so much more 

than that. It is, it is a comprehensive approach. And it is working. 

Dr. MUGYENYI. Yes. Perhaps I could——

Mr. FALEOMAVAEGA. Dr. Mugyenyi. 

Dr. MUGYENYI. Yes. Perhaps I could take you inside Africa, and 

say that stigma was at its highest because people, among other 

things, feared death. You test positive, you are going to die. 

Now, when treatment came, you test positive, you are not going 

to die; you are going to get treatment. 

Stigma, particularly in a country like South Africa, has been declining. And the driver for the decline in the stigma has been availability of life-saving treatment. 

There has also been a referral to testing. When you test, obviously you are not treating, you are testing. But people who come 

in such big numbers for testing, what do they get? They have come, 

they have presented themselves to a point of care. And when they 

present themselves to a point of care, it gives us great opportunity 

48

to give them risk-reduction messages. This is where we tell them 

about male circumcision. This is where we tell them about 

condoms. This is where we tell them about being faithful, the B 

that is being mainly applauded by faith-based organizations. This 

is where we do all of those. 

And it is through those kind of initiatives, where treatment is 

available, that we have been able to expand our operation. My organization has been able to expand 75 different places all over the 

countries, all over the country in Uganda. And everywhere we go, 

people are attracted. They know they are not going to test and be 

told the sad news today you are going to die. The clock has started 

ticking today. We give them the good news, if we find them positive, the good news that we will treat you, and what we require of 

you is to protect others against AIDS. 

Lastly, Mr. Chairman, there was another point about prevention 

of mother-to-child. There is a moral imperative here. Prevention of 

mother-to-child works wonderfully. It has almost terminated childhood AIDS that is transmitted from mother to child in rich countries, including the United States. 

In our countries, it is still a very big problem. So people support 

it because its effects are quite obvious. 

But what do the moral imperative I am talking about, Mr. Chairman, is that currently we are giving prevention to the mother, 

treatment or prevention to the mother, so that the child can be 

born HIV-free. And then we let the mother die. She is a new patient; she can’t get treatment. It is a moral imperative. 

There has not been any provision that has been put in the 

PEPFAR, with flat-lined budget, that mothers will be treated. It is 

a particular imperative in Africa because the majority of the people 

who are living with AIDS, who are coming for testing, who are actually getting infected today, they are women. This is the moral imperative that we have. 

Mr. Chairman, in 1990s the messages we were being told were 

that AIDS treatment was impossible in Africa. We are being told 

that prevention was the only thing that Africa needs. I am shocked 

to hear it this time, when it has been abundantly illustrated that 

treatment is possible in Africa, and data is coming out quite clearly, and it is showing that we can break the back of this epidemic 

by strengthened efforts on prevention, as well as strengthened efforts on treatment. 

So Mr. Chairman, this is a critical time for us in Africa. And we 

hope these points are taken in account. And we do not get people 

who take us back to the dark ages of 1990s, when all of this was 

said to be impossible. 

Mr. FALEOMAVAEGA. I would like to ask Dr. Carter, I have one 

or two questions. Did you want to comment on them? 

Ms. CARTER. I wanted to just again, building on the point about 

prevention of maternal-to-child transmission, a couple of things. 

I was talking about funding needs. The Global Fund has actually 

looked at what it is going to take. And by 2015, we could literally 

eliminate this vertical transmission from mother to child. 

If the Global Fund was fully funded at the highest-end scenario, 

it could actually cover some 75 percent of that need. If you then 

add what the Global Health Initiative could do, we could actually 

49

cover 100 percent, and we could achieve essentially ending vertical 

transmission. 

I would just also say to build on Dr. Mugyenyi’s point, is that it 

is both a moral imperative, but it is also, you know, these children 

are born, when they are born without HIV. So what are the most 

important markers for their survival? 

One is to be born without HIV, the second to have a mother who 

survives. So the importance of both of those things is absolutely 

key. 

And then just a couple of other, maybe I will comment on one 

other question, and then I will come back. I want to come back to 

Congressman Smith’s questions about the Global Fund. 

But just on the question around the issue of slums, I would only 

say obviously links between housing and issues like tuberculosis, 

and housing and issues like stress. But I think there is also the 

issue of the degree to which economic situations create 

vulnerabilities for people which then put them at risk, both physically, but also socially and economically, for these diseases. 

So I think a hugely important issue about just the economic situation, that families, in particular women, find themselves in. And 

that certainly includes housing, but the overall situation that they 

are surviving in. 

Mr. FALEOMAVAEGA. You caught me on that. I was going to ask 

you to give us an update on the Global Fund, including faith-based 

organizations; and also your opinion of whether or not the Inspector General’s recommendations are taken seriously by the Global 

Fund Secretariat. Can you respond to that? 

Ms. CARTER. Yes, I can, and I very much want to. I think, first 

on the issue of faith-based organizations, the data that, the best 

data that we have that is compiled shows that nearly 80 percent 

of the country-coordinating mechanisms that are requirements for 

the Global Fund for countries to be able to put forward grants, 

have at least one representative of the faith-based community. 

And we know that it is, the data is probably better than that, 

and I will come back to that, because they are compiling new data. 

But that is the data we have as of a couple of years ago. 

Also, what we will note is that the percentage of funding going 

to faith-based organizations as the principal recipients of Global 

Fund money and as sub-recipients is highest where they play the 

biggest role in health-care delivery. So just for example, in Western 

Central Africa, faith-based organizations—again, and this data is a 

bit outdated. It is better now, but I can give you this. 

In Western Central Africa, about 12 percent of funding; in Latin 

America, in the Caribbean, about 11 percent of the funding. And 

just to note that there have been new and major grants to faithbased organizations, including its principal recipients in Round 8, 

to a broader range of them, and some large grants to faith-based 

organizations in DRC, in South Africa. And the Global Fund is updating a study, and we will have that by the end of this year, 

which will include data from Round 8 of grants and Round 9, on 

faith-based organizations. 

And I would say just having been involved in a number of gatherings of civil society organizations, there has been a big focus on 

how do we actually increase overall the role of civil society, includVerDate 0ct 09 2002 14:52 Aug 14, 2010 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6633 F:\WORK\AGH\031110\55398 HFA PsN: SHIRL
50

ing through dual-track financing. Which, I do not know if you are 

familiar with, but since Round 8 the Global Fund has actually been 

really pushing to have two principal recipients of grants, for 

grants, one governmental, one non-governmental. And also really a 

productive push at looking at the role of faith-based organizations, 

especially again where they are a big proportion of service delivery. 

On the Inspector General for the Global Fund, just a couple, 

again a couple of broad points, and then a more specific answer to 

your question. 

So the Inspector General operates independently of the Secretariat. It reports directly to the Board. The Inspector General’s reports are required to be posted on the Web within 3 days of providing them to the Board. 

There is an enormous amount of transparency on the part of the 

Global Fund around these things. In some ways I think the Global 

Fund can sometimes suffer just by the level of transparency, which 

I think, you know, is not met by most other aid agencies. But it 

is some important things. 

The Inspector General’s budget has doubled between 2008 and 

2009. The office is now a 12-person team with a wide network of 

experts that they can contract, if needed. And this has really allowed for robust investigative capacity. 

And in addition to providing an anonymous hotline for complaints, the IG is now also proactively identifying high-risk countries based on transparency, international indices, so they can be 

more closely monitored. 

I know the Board is really very engaged in this. I think if there 

is a slight lag time sometimes in implementing all of the IG’s recommendations, I think there is transparency about that, too. But 

the Board takes this very seriously. The Fund takes it seriously, 

the Secretariat does. 

It is clear that the Board, by doubling the funding for the Inspector General’s Office, is wanting to actually strengthen and increase 

this function. So, and the Global Fund has a very strong Inspector 

General. So I feel actually very positive about the direction that 

this is going. 

Mr. FALEOMAVAEGA. Not taking anything away from Africa, but 

I wondered if any of you would comment about the two most populous nations of the world; mainly, China and India, and Asia for 

that matter. Because I am positive that HIV/AIDS is just as serious, in terms of what is happening in that region of the world. 

Does anybody care to comment on that? 

Dr. MUGYENYI. Yes, Mr. Chairman, if I may just make a brief 

comment. 

Mr. FALEOMAVAEGA. Please. 

Dr. MUGYENYI. Because AIDS is an insidious disease if it is being 

ignored. And if there is compressence, that is what happens. We 

have huge populations in Asia, especially China and India, and a 

very small percentage increase means huge numbers in those countries. 

And there is a bit of compressence which was there. And AIDS 

was spreading insidiously. It is the same situation that we are seeing and we are worried about. AIDS was allowed to spread in Africa. 

51

For example, in South Africa, which is the highest incidence 

country, with over 5 million people living with AIDS, at the time 

when Uganda had the highest peak, South Africa had very low. In 

some of the areas, it was as low as only 1.5 percent. But no action 

reactivated this disease. 

And so the fear is that if the AIDS in Asia, those huge populous 

countries, is not taken seriously, small percentages means lots of 

people. And AIDS is unforgiving if action is not taken. And it needs 

continuous awareness, as we need, even at this stage where we are 

in Africa. We can’t afford to ignore it. It is not going to stop; it is 

going to keep growing. And things will not become any easier; they 

will become more complicated. 

And in Africa, we are now trying to prevent catastrophes of need 

for second-line drugs. And need for second-line drugs, if stop the 

sharing out drugs, those who are using them, and stop people not 

taking proper dosages. Because if resistance happens in Africa, if 

we don’t take action now to make sure that access to treatment is 

available, people are going to misuse drugs. 

Because you can’t hide the fact that drugs are available. They 

are already aware. So all they can do, if we don’t give them support, is misuse them, with the consequence of resistance happening 

at public sector level; and also making the HIV complicated, HIV 

epidemic much more complicated, and much more expensive to 

manage in the future. 

In Asia and in Africa, we need not to relax, but to continue all 

of the efforts. It needs more funding, unfortunately, even when 

there is a recession. AIDS unfortunately does not go in a recession. 

Mr. FALEOMAVAEGA. If I may, the members of the panel, if you 

have any concluding statements that you would like to make, as I 

am sure members of the committee may want to submit further 

questions to each of you. It will be made part of the record if you 

would like to do that. 

So I would like to give you parting shots, or the best that you 

could relate to our hearing this morning. Dr. Hearst. 

Dr. HEARST. I don’t know if this is really a parting shot, but I 

wanted to address your question about Asia. And I think the point 

was made that even if prevalences are low, that populations are so 

large it can add up to a lot of people. 

I think we have to remember always in our thinking about AIDS 

and how to respond to it, this key difference between countries 

with concentrated epidemics and with generalized epidemics. 

The generalized epidemics have only occurred in a few countries, 

mostly in sub-Saharan Africa, for reasons that we don’t completely 

understand, but are now understanding better, when the conditions 

are right to have spontaneous transmission and a growing epidemic 

within the general heterosexual population. 

I like to tell students to think of it as if you are in a grassland, 

and somebody is throwing matches out there. If the grass happens 

to get just dry enough, the whole thing will go up in flames. Otherwise you will get a little smoldering there, and that will be it. 

And that is sort of the same thing, with the transmission dynamics, in a generalized, as opposed to a non-generalized, epidemic. 

Fortunately, there are no generalized epidemics in Asia, except 

maybe Papua New Guinea, and there never will be. AIDS has been 

52

around long enough that anywhere that there is going to be a generalized epidemic, it would have already happened. 

That doesn’t mean there is not a serious problem. In China there 

is a serious problem mainly related to injecting-drug use. 

Mr. FALEOMAVAEGA. Dr. Hearst, when you say generalized epidemic, what do you mean by that? 

Dr. HEARST. I mean an epidemic that is self-sustained in the 

general population of people who do not belong to any particular 

high-risk group. 

Unlike the epidemics in the U.S., in every rich country in the 

world, and in fact in all but about a dozen countries of the world, 

although those dozen are very important because they account for 

more than half of all AIDS cases in the world, you don’t have these 

conditions for generalized spread. So though you get infection 

transmitted in certain high-risk groups—men who have sex with 

men, injecting-drug users, in Asia commercial sex, very important, 

the sex industry, the clients. 

And then there are a few unlucky people, victims or whatever 

you want to call them, who get infected by someone who is in one 

of these groups. But the point is they don’t, on the average, you 

have to have each person on the average infecting more than one 

other person for it to become self-sustaining. 

So it stays in these concentrated groups. A few others get infected, then they infect fewer, it smolders out. That doesn’t mean 

that there aren’t millions of people infected in India, but it is not 

a generalized epidemic. And if it was going to be, it would have 

been already. 

Mr. FALEOMAVAEGA. So what makes Papua New Guinea in that 

classification as a generalized epidemic? 

Dr. HEARST. I have never been there or worked there. But from 

what little I know about it, it probably has to do with patterns of 

sexual behavior more than anything else. 

Mr. FALEOMAVAEGA. Papua New Guinea has about 7 million people, and about three to four hundred tribes. And each of those 

tribes speak different languages. So I was just curious when you 

mentioned that. I have a little familiarity with that part of the 

world. I was just curious. 

Dr. HEARST. Well, you are more familiar than I am, so I 

shouldn’t really speculate on that. 

Mr. FALEOMAVAEGA. Besides Papua New Guinea, are there other 

countries in the same category? 

Dr. HEARST. Not in Asia, there are not other countries with generalized epidemics. And that, in a way, has made it easier to respond. 

For example, in Thailand, it was mainly related to sex work; also 

to injecting-drug use. So they can, you can get very high rates of 

condom use in the brothels. Cambodia, too. And you can bring 

down the infection rates very successfully, like they have done. 

Mr. FALEOMAVAEGA. Ms. Messing. 

Ms. MESSING. Thank you, Mr. Chairman. I just want to thank 

you for having me here today. It is an honor to be able to speak 

as a part of this hearing. 

And I just want to reiterate that the U.S. Government’s funding 

for HIV prevention is working. I saw it firsthand in Zimbabwe. It 

53

is a success story. And I just encourage the United States Government to continue their robust support of PEPFAR and the Global 

Fund, so that the success can be built on, and we can bring a halt 

to the spread of HIV. Thank you. 

Mr. FALEOMAVAEGA. Well, as our Good Will Ambassador, I think 

we could not have selected a better person than you, Ms. Messing, 

for doing this. I deeply appreciate your service and your commitment in helping resolve this very serious problem in the world. 

Thank you. 

And thank you. We are honored by your presence of being here 

this morning. Thank you very much. 

Dr. Carter. 

Ms. CARTER. Thanks very much. I am going to just quickly reiterate a couple of the points I made at the beginning. I mean, just 

to say again among the opportunities we have, aggressively addressing TB, HIV, and supporting TB programs, the low-hanging 

fruit for saving lives in terms of people with HIV. 

Second, that the Global Fund is an enormously important mechanism for AIDS, but also for TB and malaria, and for broader impact 

in maternal and child health; and it leverages other donor resources, and lots of lessons to learn from how it works, so I think 

really important. 

And I guess the last thing I would say in terms of what sort of 

ended up on this panel as I think a bit of a debate around prevention and treatment, I want to say I think part of where that is coming is this feeling that the challenge of fighting over what looks 

like a pie, unlimited pie that can’t be expanded. 

And I want to say this committee and the work that has been 

done here changed the reality of what was possible around 

HIV/AIDS, and really created a new reality and how we are seeing 

this. 

I think we all support, absolutely support, the aggressive, the 

need for aggressive prevention. We have talked about PMTCT, we 

have talked about other really critical prevention. My own organization supports access to education for children, especially girls in 

Africa, because of its prevention effects, among other things. So I 

think we all support that. 

I think what we are also saying is that treatment can have important impacts on prevention. You know, and that the good news 

is if we can aggressively scale up treatment, there are models that 

do suggest that we could actually bend the curve. But it will take 

aggressive treatment and aggressive prevention to do that. 

And so, you know, I guess my message is this is working, you 

guys have led on this, the U.S. and the U.S. Congress has led on 

this. And we can’t give up now. We actually have to increase the 

resources so that we can do both, and basically bend the curve 

down. Thank you. 

Mr. FALEOMAVAEGA. Thank you, Dr. Carter. Dr. Mugyenyi. 

Dr. MUGYENYI. Thank you, Mr. Chairman. Like Dr. Carter, I 

want to conclude on that note. We need continued support so that 

we can build on the clear successes of PEPFAR, which it has 

achieved. 

And if we build on those successes that are quite clear, that are 

commented by virtually everybody who has access to the program, 

54

we can treat our way out of the epidemic. Not only with the treatment by itself. We can clearly treat our way out of this epidemic 

if we accompany it with the robust new preventive initiatives. Actually, there is not any other way with such a vicious epidemic, 

other than to scale up treatment and support robust preventive initiatives. 

Thank you, Mr. Chairman. 

Mr. FALEOMAVAEGA. Well, I certainly want to say that on behalf 

of my colleagues and the committee, to thank all of you for taking 

the time from your busy schedules, and coming here to testify, 

sharing with us your expertise and understanding of this important 

issue. 

Again, thank you so much for coming. The committee stands adjourned. 

[Whereupon, at 12:23 p.m., the subcommittee was adjourned.] 

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