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PEPFAR REAUTHORIZATION: FROM EMERGENCY

TO SUSTAINABILITY

HEARING

BEFORE THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

SEPTEMBER 25, 2007

Serial No. 110–116

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 

TOM LANTOS, California, Chairman 

HOWARD L. BERMAN, California 

GARY L. ACKERMAN, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

DONALD M. PAYNE, New Jersey 

BRAD SHERMAN, California 

ROBERT WEXLER, Florida 

ELIOT L. ENGEL, New York 

BILL DELAHUNT, Massachusetts 

GREGORY W. MEEKS, New York 

DIANE E. WATSON, California 

ADAM SMITH, Washington 

RUSS CARNAHAN, Missouri 

JOHN S. TANNER, Tennessee 

GENE GREEN, Texas 

LYNN C. WOOLSEY, California 

SHEILA JACKSON LEE, Texas 

RUBE ́ N HINOJOSA, Texas 

JOSEPH CROWLEY, New York 

DAVID WU, Oregon 

BRAD MILLER, North Carolina 

LINDA T. SA ́ NCHEZ, California 

DAVID SCOTT, Georgia 

JIM COSTA, California 

ALBIO SIRES, New Jersey 

GABRIELLE GIFFORDS, Arizona 

RON KLEIN, Florida 

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 

STEVE CHABOT, Ohio 

THOMAS G. TANCREDO, Colorado 

RON PAUL, Texas 

JEFF FLAKE, Arizona 

JO ANN DAVIS, Virginia 

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 

LUIS G. FORTUN ̃ O, Puerto Rico 

GUS BILIRAKIS, Florida 

ROBERT R. KING, Staff Director 

YLEEM POBLETE, Republican Staff Director 

PEARL ALICE MARSH, Senior Professional Staff Member 

GENELL BROWN, Full Committee Hearing Coordinator 
(III)

C O N T E N T S 

Page

WITNESSES 

Helene Gayle, M.D., MPH, Executive Director and CEO, CARE ........................ 10

Nils Daulaire, M.D., MPH, President and CEO, Global Health Council ............ 18

Joia S. Mukherjee, M.D., MPH, Medical Director, Partners In Health, Assistant Professor of Medicine, Harvard University ................................................. 26

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

and of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), School of Medicine ........................................................................ 33

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

Helene Gayle, M.D., MPH: Prepared statement ................................................... 13

Nils Daulaire, M.D., MPH: Prepared statement ................................................... 21

Joia S. Mukherjee, M.D., MPH: Prepared statement ........................................... 30

Norman Hearst, M.D., MPH: Prepared statement and material submitted 

for the record ........................................................................................................ 35

Serra Sippel, Acting Executive Director for the Center for Health and Gender 

Equity (CHANGE): Statement ............................................................................ 79

APPENDIX 

The Honorable Sheila Jackson Lee, a Representative in Congress from the 

State of Texas: Prepared statement ................................................................... 83

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

the State of New Jersey: Prepared statement ................................................... 84

Written responses from Norman Hearst, M.D., to Questions Submitted for 

the Record by the Honorable Christopher H. Smith ......................................... 85

(1)

PEPFAR REAUTHORIZATION: FROM 

EMERGENCY TO SUSTAINABILITY 

TUESDAY, SEPTEMBER 25, 2007

HOUSE OF REPRESENTATIVES, COMMITTEE ON FOREIGN AFFAIRS, Washington, DC. 

The committee met, pursuant to notice, at 10 o’clock a.m. in room 

2172, Rayburn House Office Building, Hon. Tom Lantos, (chairman 

of the committee) presiding. 

Chairman LANTOS. This meeting of the Committee on Foreign Affairs will come to order. 

Four short years ago, if you were to walk into the hallway of a 

hospital in Zambia, it would have been clogged with HIV/AIDS patients waiting to die. The lifesaving drugs, which have brought so 

much hope to those infected with the virus in wealthy nations, simply were not available to Zambia’s poor, or to those infected with 

HIV/AIDS throughout Africa. 

Our committee acted decisively to rectify this fundamental injustice. On a bipartisan basis, we rapidly approved the U.S. Leadership Against HIV/AIDS Act. This bill authorized $15 billion—I repeat, $15 billion—over 5 years, of which 55 percent was earmarked 

for treatment. 

Four years later, as we consider legislation to reauthorize this 

critically important law, the hallways of hospitals and clinics in 

Zambia and throughout Africa are once again crowded; but not 

with patients at the door of death. They are filled with hundreds 

of thousands of men, women, and children receiving lifesaving 

HIV/AIDS treatment. 

The legislation produced by our committee has yielded dramatic 

results, particularly in the arena of treatment. But the task for the 

next 5 years is not only to solidify these gains, but to reorient the 

program so that our efforts to combat HIV/AIDS will be sustainable 

for generations to come. 

To be sustainable, our HIV/AIDS program must dramatically 

strengthen the healthcare delivery systems in nations ravaged by 

the deadly virus. To be sustainable, our program must find new 

and creative ways to delivery the ABC prevention message. To be 

sustainable, our program and the programs under the Global Fund 

must work with NGOs and governments to battle HIV/AIDS in a 

cost-efficient, transparent, and effective manner. 

So as our committee embarks on rewriting the U.S. Leadership 

Against HIV/AIDS, those will be our marching orders. We will increase dramatically the funding for this vitally important program, 

with a new-found emphasis upon sustainability at its core. 
2

Working in the same bipartisan manner in which the original act 

was created, we will find new efforts to encourage doctors and 

nurses to stay in Africa and other HIV/AIDS-ravaged nations, 

where they are clearly most needed. We will launch new programs 

to train hundreds of thousands of physicians, nurses, community 

health workers, and to find gainful employment for the millions of 

teenagers across the African Continent who were orphaned by 

AIDS while they were very young. 

And we will create new efforts to bring lifesaving medicine to 

rural areas. With just a bit of modern technology, a village health 

worker can immediately connect a patient with a doctor located in 

a major city, and use a bicycle to bring life-sustaining medicine to 

the poor in the countryside. 

Working in a bipartisan manner, we will increase the sustainability and effectiveness of our prevention efforts. With an HIV 

prevalence rate of 17 percent in Zambia, 18 percent in South Africa, and 24 percent in Botswana, we clearly have our work cut out 

for us. 

But if we stick to the ABC prevention message and find new and 

creative ways to reach the most vulnerable populations, these absolutely staggering rates can and will come down. 

To maintain the bipartisan consensus behind this initiative, we 

must recognize that each element of the ABC approach has value. 

For kids in elementary school, abstinence education is right on target, particularly when it empowers children to make correct choices 

in all aspects of their lives. 

For dating and married couples, awareness of one’s HIV status 

and faithfulness are vital to stemming increases in infection rates. 

And for couples who don’t know whether they have HIV, or 

where one partner has been tested and found free of the virus, 

condoms are essential. Unlike the guidance issued by the Executive 

Branch, I do not believe that condoms are only for prostitutes and 

truck drivers. 

Working together we can fine-tune our prevention programs, and 

literally save millions of lives. Working together we will guarantee 

nutrition with treatment, so that patients no longer stop medicines 

because they have nothing to eat. Working together we can revitalize Africa’s healthcare system, and leave a real legacy for future 

generations. 

Working together, we can dramatically boost funding for our 

global HIV/AIDS programs, and help to ensure that millions more 

kids don’t lose their parents to this deadly scourge. 

We have had some genuine success so far. But if we don’t help 

to build in the target countries the capacity and the will to sustain 

this struggle for the long term, then all our good work may turn 

out to have been for naught. 

It is my pleasure now to turn to my friend, the ranking Republican member of the committee, Ileana Ros-Lehtinen, for any remarks she may care to make. 

Ms. ROS-LEHTINEN. Thank you so much, Mr. Chairman, for holding this hearing on this important issue. 

When the committee last met in April to discuss the President’s 

Emergency Plan for AIDS Relief (PEPFAR), attention was properly 

placed on what has been accomplished. Through PEPFAR, the 
3

American people have helped provide compassionate care for some 

4.5 million people impacted by HIV/AIDS, including 2 million orphans and vulnerable children. 

We have supported the provisions of anti-retroviral treatment for 

nearly 1 million people with an estimated 50,000 new people gaining access to treatment each month. And we have made significant 

advances in preventing new infections from occurring, including by 

providing ARV for HIV mothers during over half a million pregnancies. 

These accomplishments are a testament to the generosity of the 

American people, the bipartisan commitment of this body and the 

administration, and the tireless dedication of our implementing 

partners on the front lines of this pandemic. 

But more and more people become infected each day. According 

to UNAIDS, an estimated 4.3 million new infections occurred in 

2006 alone. Clearly, much more needs to be done. 

In May the President announced his intention to seek authorization from Congress to commit an additional $30 billion to the 

PEPFAR initiative over the next 5 years. The President’s demonstrated commitment to fighting the global scourge of HIV/AIDS 

through PEPFAR and the competence of the Global AIDS Coordinator, Ambassador Mark Dybul, has helped set a positive tone as 

Congress seeks to reauthorize the U.S. Leadership Against 

HIV/AIDS, Malaria, and Tuberculosis Act, which will expire this 

year. 

But given the number of lives and the amount of money that are 

at stake, we cannot afford to make mistakes in this reauthorization. We must focus our efforts on what works, and move toward 

sustainable solutions. 

During the reauthorization debate there will be much discussion 

about how to transition PEPFAR from an emergency program to a 

sustainable one. Some are advocating that PEPFAR take on additional challenges including placing greater emphasis on gender 

issues, deficits in healthcare systems, and the lack of food security 

for those with HIV/AIDS. 

While there is a great deal of merit to some of these arguments, 

I urge caution, because if PEPFAR is directed to take on a universe 

of problems that plague the focus countries, we risk reducing a program that is, reducing it to a program that is a mile wide and an 

inch deep. We must remain focused on the central objectives of providing care and treatment to those impacted by HIV/AIDS while 

expanding efforts to prevent new infections from occurring. 

Members will also hear arguments in favor of evidence-based decision making with regard to our prevention, care, treatment interventions. I could not agree more. I cannot imagine anyone making 

a rational argument for spending an additional $30 billion on a 

program that was anything less than effective. 

Then there are those who call for both sustainability and evidence-based decision making in the same breath that they advocate 

for the removal of the abstinence earmark in the Leadership Act. 

Abstinence and fidelity programs are working, where the traditional focus on condom promotion that dominated the U.S. strategy 

for the last 17 years of the pandemic has failed. 
4

Yet prior to the imposition of the earmark, the United States invested little, if anything, in the AB programs. If implementers had 

not been compelled to adjust their programs, I am not confident 

that they would have embraced the ABC approach, with a strong 

emphasis on the A and B, that has proven effective in countries 

like Uganda, Botswana, Kenya, and elsewhere. 

And even now that a consensus has emerged that the AB programming is central to an effective prevention strategy, I am still 

not confident that it would be implemented if not for the earmark. 

Dr. Norman Hearst, a respected leader in the field of HIV/AIDS 

treatment and prevention for the last 20 years, will testify to that 

today. Dr. Hearst was commissioned by UNAIDS to do a study on 

the impact of condom promotion in areas heavily impacted by 

HIV/AIDS. He will readily admit that he initially undertook the 

study with a bias toward condom promotion. However, his research 

revealed that the promotion of condoms, in the absence of strong 

abstinence and fidelity programs, actually led to increases in new 

infections. 

When he reported this to UNAIDS, they refused to publish his 

work. Fortunately for us, his work has since been published and 

has become part of a growing consensus among HIV professionals 

that, while condoms play an important role in HIV/AIDS prevention, abstinence and fidelity programs are essential to successful 

and sustainable prevention efforts. 

Mr. Chairman, I hope that members on both sides of the aisle 

will heed the advice of the advocacy groups and consider the evidence before making any decision to strike the AB earmark. 

The PEPFAR program, Mr. Chairman, is a magnificent demonstration of the good that can be done when Democrats and Republicans work together to solve the most serious of problems. 

I look forward to working with you, Mr. Chairman, and with our 

colleagues to ensure that the Leadership Act is reauthorized and 

that our PEPFAR program is as successful as possible. 

Thank you for the time, Mr. Chairman. 

Chairman LANTOS. Thank you very much. And before turning to 

my next colleague, let me just state for the record that I am about 

to manage the most important piece of legislation on the floor with 

regard to Iran. I would like to ask my friend from New Jersey to 

take the chair. 

Mr. PAYNE [presiding]. Let me begin by commending the chairman, Mr. Lantos, for convening this very important hearing with 

representatives from the HIV/AIDS research and advocacy communities, and organizations that helped implement the President’s 

Emergency Plan for HIV and AIDS Relief, or PEPFAR, as it is 

known. 

Traveling through Africa, one of the programs that most people, 

whether they are in government, in the cities, or in the villages, 

know about is the PEPFAR program. And we believe that it has 

had a major impact in the war against HIV and AIDS. Of course, 

it is far from adequate. 

In the 4 years since Congress passed the original legislation authorizing PEPFAR, the professionals from these organizations had 

proven to be a critical resource not only in helping carry out the 

program, but also as a resource to Congress, as we engage in our 
5

oversight responsibilities. And they have been invaluable in terms 

of the feedback and analysis they have provided, as this committee 

writes legislation to reauthorize the initiative. 

I will be calling on the expertise of the NGO community on October 9 at a hearing of the Subcommittee on Africa and Global 

Health, which is specifically focused on the issue of the integration 

of food and nutrition into treatment programs supported through 

PEPFAR. It is an area that we believe needs a lot more examination. We believe that there is a relationship between the success of 

the program and adequate nutrition and food. 

I hope that our witnesses today will touch on that issue in their 

testimonies. In addition, I am interested in their analysis regarding 

PEPFAR’s current prevention strategies, and how these strategies 

can be improved. 

As we all know, for every one person we put on anti-retroviral 

treatment, five additional people become infected with HIV. We 

cannot treat our way out of this disease. Developing and improving 

prevention programs will be vital as the United States transforms 

its emergency response to a sustained commitment to fight the 

HIV/AIDS pandemic. 

It is clear to me that while much has been accomplished in terms 

of fighting HIV/AIDS, much more remains to be done. Only 28 percent of Africans needing anti-retrovirals are receiving them. 

Shockingly, over 85 percent of African children who need ARVs are 

going without. 

If we are to stop the spread of HIV/AIDS, we are going to have 

to redouble our efforts, both financially and programmatically. 

Again, I commend the witnesses for coming here, and I certainly 

look forward to your testimonies. 

With that, I will yield to Mr. Smith, the ranking member on the 

Subcommittee on Africa and Global Health. 

Mr. SMITH OF NEW JERSEY. Thank you very much, Mr. Chairman. I want to thank you and Congressman Lantos, the chairman 

of the full committee, for calling this timely hearing in anticipation 

of the reauthorization of the President’s Emergency Plan for AIDS 

Relief. 

In the short 4 years of its existence, PEPFAR, crafted so skillfully by Chairman Hyde, who was then chairman of the full committee and prime sponsor of the bill, along with Mr. Lantos, and 

many of us who had very strong concerns about this issue—I was 

very proud to have been a co-sponsor—has transformed the nature 

of this pandemic. 

In 2003, HIV/AIDS was a ravaging death sentence that was destroying individuals, families, and entire communities with little or 

no relief in sight. Now, it is, to be sure, an ongoing and desperate 

crisis, but it is being restrained, and can be restrained further, and 

hopefully ended, if it is addressed through sufficient resources and 

appropriate evidence-based policies. 

Although anti-retroviral treatment has been pivotal in slowing 

the tide of the pandemic, we cannot rely on ARVs as the centerpiece of a sustainable program. As we will hear during today’s testimony, for every person who is placed on ARVs, there are six new 

infections. So, we must focus our efforts on learning what has 

worked up to now in reducing the prevalence rates of HIV/AIDS 
6

and concentrate our resources on expanding those successful strategies. 

Prior to PEPFAR and the implementation of the 33 percent prevention spending requirement on abstinence and be faithful programs, almost no one, USAID included, even considered devoting 

resources to these measures. I am told that some USAID personnel 

in the field even laughed at the idea of abstinence training when 

PEPFAR was first being implemented. 

Most, if not all, of HIV/AIDS prevention programming consisted 

of condom marketing and distribution. Yet, as we will hear from 

our distinguished witness, Dr. Norman Hearst, and as Ileana RosLehtinen noted a moment ago, the condom approach did not work 

in countries where the pandemic has spread among the general 

population which constitute a majority of the world’s infections. 

The PEPFAR comprehensive evidence-based approach adopted 

the successful ABC model that originated in Uganda, and the success of reducing HIV prevalence rates through sexual behavioral 

change is being replicated in other PEPFAR-focused countries. 

This approach is showing other positive outcomes, as well. For 

example, a PEPFAR-funded program in Schibello Basic School in 

Zambia emphasizes abstinence as part of a holistic life-skills training program. Since the program was implemented 2 years ago, the 

number of pregnancies among the 520 schoolgirls, grades 5 to 9, 

has dropped from 13 in 2003 to 2004 to zero so far this year. School 

management also attributes the program with significantly enhancing academic performance. 

I am deeply disturbed, Mr. Chairman, by the insinuations of 

some that sexual behavior change is not possible for Africans. Father Thomas Williams, in a May 17, 2007, article in the National 

Review, notes that he has spoken to numerous Africans who find 

the egregiously false Western supposition that they are going to do 

it anyway not only to be insulting, but racist. He notes that prejudice against Africans with no self-discipline or control over the sex 

drive simmers just beneath the surface of much anti-abstinence 

propaganda. 

On the other hand, the question is appropriately raised as to why 

those who consider themselves experts are refusing to accept the 

evidence about the success of behavioral change; and if they do accept the evidence, why they are opposed to the AB spending requirement. 

With the spending requirement, the U.S. is the only major international donor providing substantial support to this proven prevention strategy. Without it, we are faced with the specter of returning 

to a failed condom-centric approach, and to the devastating loss of 

human life of the pre-PEPFAR era. 

Finally, Mr. Chairman, I am deeply concerned, and, quite frankly, outraged, that some pro-abortion NGOs are attempting to hijack 

PEPFAR and other noble initiatives to promote the slaughter of 

unborn children in Africa and around the world. Pro-abortion 

groups are shamelessly using HIV/AIDS funding as the Trojan 

Horse to facilitate policies that reduce unborn children to expendable commodities. 

And let me be very clear. I am not injecting this into the debate; 

they are. Abortion methods, Mr. Chairman, are violence against 
7

children. Dismembering a baby with sharp knives or chemically 

poisoning a child with drugs and toxic chemicals can never be construed as benign or compassionate. It is child abuse. 

Let us get about reauthorizing this legislation. Let us do it without a wrap-around that would include the killing of unborn children. 

I yield back the balance of my time. 

Mr. PAYNE. Thank you very much, Mr. Smith. Ms. Woolsey? 

Ms. WOOLSEY. No, Mr. Chairman, I am waiting to hear our witnesses. Thank you. 

Mr. PAYNE. Mr. Fortenberry is not here. Oh, here he is. Go right 

ahead. 

Mr. FORTENBERRY. Thank you, Mr. Chairman. I appreciate the 

opportunity to be a part of this hearing today, and thank the witnesses for your commitment to individuals and communities suffering from HIV/AIDS. 

The deadly scourge of HIV/AIDS, which now ranks among the 

world’s leading causes of death, claims most of its lives in Africa, 

the world’s most impoverished continent. It is particularly devastating in sub-Saharan Africa, where healthcare infrastructures 

are least able to support the burgeoning numbers of infected persons. 

While this hearing is focused on developing a sustainable plan to 

address HIV/AIDS, it is important to point out that unless we also 

develop a sustainable plan to help address the glaring shortage of 

healthcare workers and basic health infrastructures throughout 

sub-Saharan Africa, the impact of our HIV/AIDS efforts risks being 

diluted, at best. 

According to the World Health Organization, the rate of infections is rapidly outpacing the rate at which infected individuals are 

treated. While the United States leads the world in providing treatment and care for communities affected by HIV/AIDS, notably 

through our PEPFAR program, we will continue to see millions of 

deaths unless we grapple more effectively with the issue of prevention. 

As we stand before a $30 billion reauthorization of PEPFAR, I 

am acutely aware of the need to ensure that Federal funds available for HIV/AIDS prevention and treatment are channeled into 

the most effective evidence-based programs. Our ultimate objective 

is to save lives. 

Uganda stands out as an example. Between 1991 and 2004, 

Uganda witnessed a decline in HIV prevalence from 15 percent to 

5 percent. During this time, Uganda placed a decided emphasis on 

abstinence and fidelity, consistent with cultural norms. Yet such 

approaches seem to draw the most critical scrutiny. 

It is my hope, Mr. Chairman, that our panel will examine these 

factors in an objective manner, as well as the delivery model for 

care of our most vulnerable and needy throughout the world. 

Thank you, Mr. Chairman. 

Mr. PAYNE. Thank you very much. Mr. Miller? 

[No response.] 

Mr. PAYNE. Mr. Scott? 

Mr. SCOTT. Yes, very briefly, Mr. Chairman. Because I believe 

this is such a very, very important hearing. It is absolutely stag-
8

gering to hear the report that 90 percent of the children with 

HIV/AIDS is from Africa, one continent. And even worse than that, 

90 percent from a certain part of that continent, sub-Saharan Africa. 

It just seems to me that this presents an extraordinary opportunity where a focused, concentrated effort could be made. Just 

imagine if 90 percent of the children with HIV/AIDS were from the 

United States. Just think of that. And if we think of it in that perspective, the grand dynamic of this situation I think would be registered even more deeply. 

And so, Mr. Chairman, I think the fundamental question that I 

believe needs to be asked today is, given the fact that PEPFAR is 

doing, in my estimation, a very good job, it can do a better job. 

Could that job be done better if there is a greater focus on the resources of PEPFAR to target just HIV/AIDS? And of course, we recognize malaria and the other diseases that are in here certainly 

can be dealt with, and should be; but neither is the life sentence 

that HIV/AIDS is. 

So, Mr. Chairman, I just wanted to make those opening comments, thank this committee for bringing this extraordinary and 

timely hearing. And my hope is that this committee will move to 

even bring a better light and a brighter light to be shined on this 

extraordinary problem in Africa. 

And I certainly look forward to joining you, Chairman Payne, on 

your next trip to Africa, so that we can bring an even greater degree of attention and move with greater resources to help the people of Africa fight this terrible, terrible disease. 

Thank you and I yield back. 

Mr. PAYNE. Thank you very much, Mr. Scott. Mr. Wu? 

[No response.] 

Mr. PAYNE. Mr. Green? 

Mr. GREEN. Thank you, Mr. Chairman, and I will be brief like 

my colleague from Georgia. 

I want to thank you for holding the hearing on the President’s 

Emergency Plan for AIDS Relief. The HIV/AIDS epidemic is having 

a devastating impact on children and families worldwide, and nowhere is it more prevalent than in Southern Africa. Roughly 40 

percent to 60 percent of all deaths of children under the age of five 

are caused by HIV/AIDS or related complications. 

Most children living with HIV acquired the disease through 

mother-to-child transmission, or MTCT, which can occur during 

pregnancy, labor and delivery, or breastfeeding. In the absence of 

any intervention, the risk of such transmission is 15 percent to 30 

percent in non-breastfeeding populations. Breastfeeding by an infected mother can increase it to 45 percent. 

The risk of MTCT can be reduced to under 2 percent by interventions that include the prevention of anti-retroviral vaccines, when 

PEPFAR’s primary mission should be to focus on mother-child 

health and the prevention of the MTCT. 

In the area of children’s health and prevention, I would like to 

recognize Baylor College Medicine and Baylor International Pediatric AIDS Initiative for the work they have done in Africa, as elsewhere in the globe. Approximately 80,000 HIV-infected children 

and families will receive care and treatment over the next 5 years 
9

in two treatment centers. The initiative opened in Constanta, Romania, and Catarrhine, Botswana. 

The reauthorization should encourage PEPFAR to partner with 

projects such as the Baylor Pediatric AIDS Initiative with the expertise that they can provide. As someone who strongly believes we 

need to address tuberculosis and malaria both abroad and here in 

the United States, I believe PEPFAR has served, also serves an important purpose in addressing the connection between AIDS and 

TB-related deaths. The leading cause of death among individuals 

who die from HIV/AIDS in Africa is not directly from these diseases, but from tuberculosis. 

I have worked with any number of our colleagues, including Mr. 

Engel of this committee, to ensure necessary attention and resources given to combat these diseases collectively. As we look to 

reauthorize PEPFAR, I think it is important we continue to address tuberculosis and coordination with HIV/AIDS treatment. 

Also, Mr. Chairman, thank you for holding the hearing. I will 

look forward to our panel. I yield back our time. 

Mr. PAYNE. Thank you very much. Ms. Watson? 

Ms. WATSON. Thank you, Mr. Chairman. HIV and AIDS have a 

devastating impact, not just on individuals, but on whole societies. 

And I think it is important that when we confront this issue, we 

pay equal attention both to helping patients and nations stay 

healthy. 

Education can be an important and cost-effective social vaccine 

against HIV/AIDS. The cognitive skills required to make informed 

choices about HIV/AIDS and the risk and behavior are strongly related to education levels. Additionally, children who enroll and remain in school often have access to curriculum and information on 

HIV/AIDS prevention. 

Despite the relationship between education and prevention, basic 

education is not included in PEPFAR’s HIV/AIDS prevention strategy. And there is not enough coordination between basic education 

and HIV/AIDS programs on the ground. 

I am not advocating for PEPFAR to become an educational program, and I think that would be a poor use of resources. But I 

would like to see us emphasize more how investing in basic education programs can, among other things, help us fight and help 

our fight against HIV. 

Thank you, Mr. Chairman. I yield back. 

Mr. PAYNE. Thank you very much. We are fortunate today to 

have four exceptionally accomplished members of the medical profession, all of whom have many years of experience with the issue 

before us. And so let me thank each of you for taking the time out 

to testify here before our committee. 

We will hear the witnesses in this order. Dr. Helene Gayle, who 

is president and CEO of CARE, a position to which she came after 

serving as director of HIV and Reproductive Health with the Global 

Health Program at the Bill and Melinda Gates Foundation. She 

was director of the National Center for HIV/STD and TB Prevention with the Centers for Disease Control and Prevention, and 

served for 20 years in the U.S. Public Health Service, retiring with 

the rank of Rear Admiral. 
10

We will then hear from Dr. Nils Daulaire, who is currently serving as president and CEO of the Global Health Council. He is a 

former Deputy Assistant Administrator for Policy and Senior International Health Advisor for the U.S. Agency for International Development. He has represented the United States at many major 

international conferences. Dr. Daulaire, who is a Phi Beta Kappa 

graduate of Harvard University, went on to Harvard Medical 

School for his M.D., and later earned his MPH at Johns Hopkins. 

He has worked in Nepal, Mali, Haiti, Bangladesh, and a number 

of other countries. Incidentally, he speaks seven languages. That is 

probably helpful. 

Dr. Mukherjee specializes in the treatment of MDRTB and HIV 

and AIDS in the resource-poor countries and communities. She divides her time between Brigham Women’s Hospital in Boston, and 

clinical sites in Peru, Haiti, and Russia. Dr. Mukherjee is boardcertified with pediatrics, infectious diseases, and internal medicine. 

She is an attending physician for the adult and pediatric infectious 

disease services at BWH in Massachusetts General Hospital, and 

is a member of the faculty at the Harvard Medical School. 

And finally, we have Dr. Norman Hearst, who is a physician and 

public health specialist at the University of California, San Francisco. The past 20 years he has been a leader in the field of international HIV/AIDS epidemiology and prevention, and has authored 

over 100 papers and 250 conference abstracts on the subject. He 

has also served as a consultant to WHO, UNAIDS, USAID, and 

various other governmental and international organizations. 

Thank you for being here. We will start, as I indicated, with Dr. 

Gayle. 

STATEMENT OF HELENE GAYLE, M.D., MPH, EXECUTIVE 

DIRECTOR AND CEO, CARE 

Dr. GAYLE. Thank you. It is my pleasure to join this discussion 

on the reauthorization of PEPFAR. As many people have already 

stated, there are many reasons to be proud of what PEPFAR has 

already accomplished, including the incredible leadership role that 

the U.S. Government has taken in confronting this epidemic. 

CARE is privileged to serve HIV-infected individuals and communities in over 40 countries, including 11 of the 15 PEPFAR countries. As an organization dedicated to eliminating extreme poverty, 

our programs addressing HIV and AIDS are done with a comprehensive view that looks at the broader landscape of development. And it is from that perspective that I am going to be focusing 

my comments today. 

In fact, we believe that looking at HIV in the development context is the best way of assuring sustainability in our response to 

HIV and AIDS in poor communities that are disproportionately impacted by HIV. 

As you know, the Institute of Medicine evaluated this program 

and said that this whole issue of moving from a short-term resultsoriented, short-term results mode to a sustainable impact model is 

really what we need to focus on. And so I think that the IOM approach is the real focus of our comments. 

In our 20 years of work on HIV and AIDS, CARE has learned 

that addressing the crisis effectively obliges us to invest in a range 
11

of sectors, from food security to micro-finance, to girls’ education, 

and to promoting major cross-cutting imperatives, such as the empowerment of girls and women. 

Addressing HIV and AIDS solely as a medical challenge is like 

treating the symptoms, but not really the cause of the disease. So 

we feel that the objective of having a long-term sustainable impact 

on the epidemic needs to focus on three areas. 

First of all, addressing HIV and AIDS within the development 

framework. Second, looking at, focusing on the vulnerability of girls 

and women. And third, investing in scaling up of evidence-based 

prevention strategies. And it is on those three recommendations 

that I will focus my comments today. 

First of all, talking about addressing HIV and AIDS within a development framework, we think that Congress should strengthen 

U.S. global AIDS programming by giving PEPFAR a more sustainable, long-term objective that does strengthen the development 

interfaced overall, including new funding and more flexibility to integrate existing funding for vital programs like family planning 

and for food and income security and fostering a more comprehensive approach to HIV and AIDS by making wrap-around programs 

truly effective. 

We cite several examples in our written statement, and I am not 

going to go into all of those here, but just give one example of a 

country that we work—Malawi—where adult HIV prevalence is 14 

percent, and food and economic security is intertwined with HIV 

and AIDS. 

In Malawi, CARE focuses on innovative strategies to use our food 

security and economic development programming to address HIV 

and AIDS more effectively. In our program there, we organized a 

diverse set of interventions, including village savings and loans 

programs, or micro-credit programs; vocational training; food aid as 

a safety net; training in home-based care; access to HIV-testing 

services; and support groups for stigma reduction. 

We have seen by having this more integrated approach that we 

have been able to achieve an impact in many directions, including 

enhancing food and economic security, which reduces the pressure 

for women to engage in survival sex, while better nutrition has 

been able to help delay the symptoms and onsets of symptomatic 

AIDS in people who are HIV-positive and improved adherence to 

AIDS medication. 

So we think that it is that integrated approach that has the best 

long-term outcome, and will have the most sustainable impact on 

both prevention as well as treatment efforts. 

Specifically, we encourage Congress in this regard to require 

long-term, integrated, multi-sectoral strategies for our global AIDS 

response; provide multi-year—at least 3-year—minimum funding 

that fosters a more sustainable mindset; focus on achieving longterm impact, rather than generating quick results, by strengthening the impact measures; and also addressing social processes 

that underpin the vulnerability to HIV. And then making wraparound services actually work, and work effectively, combining new 

funding and fostering additional coordination with existing funding. 
12

And also, we think that harmonizing U.S. Government planning 

with national governments and other donors will be critical to 

bringing a variety of funding streams to strengthen programs. 

Second, focus on the vulnerability of women and children, the 

women and girls at risk of contracting HIV. Given the increase impact that HIV is having on women, where 50 percent of new HIV 

infections are occurring in women, 60 percent of new HIV infections in Africa are occurring in women, Congress should invest in 

comprehensive approaches that engage the multiple factors that 

drive the vulnerability and low status of girls and women, and integrate HIV/AIDS responses with reproductive health services and 

improved access to family planning. 

Specifically, we urge Congress to advance comprehensive programming through PEPFAR that addresses the social and economic 

and cultural factors that affect the vulnerability of women and 

girls, and give new emphasis on improving gender equity and women’s status. 

Third, integrate and link HIV and AIDS programs and reproductive health programs, especially family planning, and strengthen 

efforts to reduce unmet family planning needs among HIV-infected 

women. 

Fourth, require mandatory operational guidance for country programs on gender-responsive programming. 

And my final point, invest in scaling up evidence-based HIV 

strategies. Ultimately, as you said, Congressman Payne, we can’t 

treat our way out of the HIV/AIDS epidemic. We must immediately 

increase our efforts to deliver comprehensive, evidence-based prevention programming worldwide. We, therefore, urge Congress to 

specifically identify prevention as the highest priority for U.S. 

Global HIV/AIDS Programming over the next 5 years, and ensure 

that funding is available to deliver universal access to the prevention services essential to our efforts to combat the epidemic. 

We must also ensure that countries have the ability to tailor prevention strategies to match the epidemiology of each country. We 

recommend that the reauthorization avoids specific budget allocations and restrictions, such as the abstinence-until-marriage earmarks, and instead support countries’ ability to shape their programs to meet their needs and their cultural traditions. Advance 

an ABC-plus strategy to address the underlying vulnerabilities by 

confronting social norms that put women and girls at risk, as well 

as targeting efforts to prevent gender-based violence; enhance food 

and economic security; secure property rights; and improve access 

to reproductive health services. While we believe that the ABC 

strategy is critical and has to be a foundation, we feel that an ABCplus approach that really looks at some of these other issues that 

are critical for the vulnerability of women is essential, and that we 

just deploy evidence-based strategies to curb HIV transmission 

among the groups at highest risk, particularly in countries that 

have not yet faced a generalized epidemic. That includes sex workers, injection drug users, men who have sex with men, and prisoners, if we really want to have a truly global impact on this epidemic. 

Again, I will end there, but I just want to say that I think we 

have an incredible opportunity, through PEPFAR, to continue to 
13

exert extraordinary leadership in the global fight against HIV and 

AIDS. These last 5 years have shown the American people and our 

friends and partners around the world something unique: That the 

power of hope, coupled with action to advance our highest aspirations for the common good, can really have an incredible impact on 

this epidemic. 

I thank you, and I look forward to entertaining your questions. 

[The prepared statement of Dr. Gayle follows:]

PREPARED STATEMENT OF HELENE GAYLE, M.D., MPH, EXECUTIVE DIRECTOR AND

CEO, CARE 

Mr. Chairman, Ranking Congresswoman Ros-Lehtinen, Members of the Committee. Thank you for the opportunity to join this important discussion on the reauthorization of the President’s Emergency Plan for AIDS Relief or PEPFAR. There 

are many reasons to be proud of what PEPFAR has accomplished. The devastation 

of the HIV pandemic at the dawn of the 21st century demanded an urgent response, 

and the U.S. government rose to that challenge—demonstrating vital leadership, 

taking determined action and investing unprecedented resources. I congratulate the 

U.S. government on its leadership, and applaud President Bush’s pledge to amplify 

the U.S. government’s commitment to fighting HIV and AIDS. 

I welcome the keen interest that Members of Congress have shown in the oversight of PEPFAR’s performance and in the development of PEPFAR’s successor. 

Your engagement is critical: PEPFAR is a precious resource and we must be absolutely sure that its investments will yield optimal, long-lasting results. This moment—of looking back at PEPFAR’s past and looking forward to its future—calls for 

a spirit of openness, honesty and collaboration. It is in that spirit that I engage with 

you today. 

I speak today on behalf of CARE, an international development and relief organization that has worked for more than 60 years in some of the poorest communities 

in the world. CARE began working on HIV and AIDS twenty years ago. We now 

address HIV and AIDS in over 40 countries with support from a range of public and 

private donors and a multi-year portfolio of HIV and AIDS programs totaling $183 

million. CARE works in 11 out of the 15 PEPFAR focus countries and in four of 

the five non-focus countries that receive more than $10 million annually from 

PEPFAR. CARE’s approach to HIV and AIDS is typically community-based and 

multi-sectoral. We address HIV and AIDS comprehensively as part of the broader 

landscape of poverty, and focus on addressing the vulnerability of women and girls 

to HIV and AIDS. 

FROM EMERGENCY TO SUSTAINABILITY

When PEPFAR got started, confronting HIV and AIDS with the urgency of responding to a large-scale emergency was important. Make no mistake about it: 

AIDS is still a crisis of enormous proportions, so that sense of urgency must remain. 

But we must now transform PEPFAR into a program that is capable of responding 

to HIV and AIDS as a protracted challenge that has complex social, economic and 

cultural dimensions, in addition to the obvious health dimension. That calls for addressing HIV and AIDS within a development framework, integrated with other key 

health issues. Otherwise, our investments may effectively address the consequences 

of HIV and AIDS in the short-term, while making little headway in attacking the 

underlying drivers of the pandemic over the long-term. This is a marathon, not a 

sprint: we need a coherent, sustainable strategy for the hard work ahead of us—

and that is what we are here to discuss today. 

As you know, the Institute of Medicine (IOM) evaluated U.S. global AIDS programming and concluded that PEPFAR must transition from an emergency, shortterm results mode to a much greater focus on sustainable impact. Given that sustainability will be the linchpin of PEPFAR’s long-term success, it is worth probing 

what that concept signifies. One type of sustainability relates to a set of activities 

continuing, even after their initiator exits. Another type refers to the durability of 

a certain impact: for example, a vaccine that provides immunity to a disease. A 

deeper form of sustainability is reflected in the ability of societies to maintain processes of economic, social and cultural transformation. In the case of an epidemic like 

AIDS that cannot be disentangled from the economic, social and cultural factors 

that drive it, we must pursue all three forms of sustainability, in particular the 

deepest, most durable form. 
14

Over the years, CARE has learned many hard lessons about sustainability and 

impact. We have discovered that interventions that advance goals that are easily 

measurable in the short-term often fail to add up to long-term impact. We have also 

learned that a variety of well-designed projects may not have impact of much depth 

or scale unless they fit within a broader framework. These lessons are useful for 

PEPFAR too. CARE’s experience with PEPFAR, often echoed in the IOM evaluation, 

indicates the following: that PEPFAR’s tendency to fund short-term interventions 

often neglects the social processes vital for real local ownership; that its emphasis 

on quick results produces incentives to ‘‘demonstrate big numbers’’; and that its narrow focus and compartmentalized approach to prevention, treatment and care inhibit integrated, comprehensive programming. These are features of PEPFAR that 

must change, if lasting impact and real sustainability are to be realized. 

POSITIONING PEPFAR WITHIN A DEVELOPMENT FRAMEWORK

The problems that afflict poor communities are woven together in a complex web. 

Solving these problems requires changing the weave of that web, rather than addressing each strand one by one. In the case of HIV and AIDS, the disease is often 

not the top priority for many poor people. Time and again, mothers tell us that feeding their children is their main worry. For girls, it is often going to school or avoiding early marriage. For sex workers, it is often harassment and discrimination. The 

transformation of this broader landscape—of inequality, violence and hardship—into 

something more equitable, safe and prosperous is the challenge of development. 

Doing so is vital to addressing the often synergistic drivers of vulnerability to HIV 

and AIDS. That is why sustainable, effective HIV and AIDS interventions must be 

closely linked to development. 

Addressing HIV and AIDS solely as a medical challenge is like treating the symptom but not the cause. Over the years, CARE has learned that to attack the drivers 

of the epidemic, we must deploy comprehensive and well-integrated approaches tailored to each context. For example, in Malawi, where adult HIV prevalence is 14 

percent, food and economic insecurity is intertwined with HIV and AIDS. So CARE 

focuses on how our food security and economic development interventions can be 

platforms to address HIV and AIDS. We organize a diverse set of interventions, including village savings and loans groups, vocational training, food aid as a safety 

net, training in home-based care, access to HIV testing services, and support groups 

for stigma reduction. This integrated approach attacks HIV and AIDS from many 

angles: for example, enhanced food and income security reduce pressure for women 

to engage in survival sex, and resulting improvements in nutritional status help 

delay the onset of AIDS in HIV-positive people and improve efficacy of ART. Mai 

Chautsi, who belongs to a support group for people living with HIV and AIDS, told 

us that micro-enterprise skills have enabled members of her group to improve their 

health and nutrition. She said: ‘‘With our profits, we are able to buy nutritious food, 

especially proteins, which we could not afford in the past. Some members would 

miss accessing their ARVs at the hospital because they could not afford transport 

fares. They can now go to the hospital on time.’’

Another example is the ‘‘5 x 5’’ model of early childhood development (ECD) that 

CARE has developed to comprehensively address the needs of OVC under five years. 

The ‘‘5 x 5’’ model advances interventions in five areas: nutrition, child development, 

economic strengthening, health and child protection. The model also engages at five 

different levels: the individual child, the caregiver or family, child care settings, the 

community (including health services) and the national policy arena (particularly related to health and education). The model seeks to intervene at early childhood to 

enhance the long-term potential of very young children affected by HIV and AIDS. 

The child care setting is the entry point but the strength of the ‘‘5 x 5’’ approach 

is the linking of actors and services, and its strong investment in community ownership. 

In Busia, a town along a busy transport corridor in Uganda, some young mothers 

are children themselves and are far from home. These young women are paired up 

with ‘‘mother mentors’’ (older mothers) who can coach them on parenting skills, educate them on HIV prevention and link them to family planning services. In Kibera, 

an urban slum in Kenya, two health centers are formally linked to the ECD centers, 

and children from the ECD centers receive a variety of health services from immunizations to monitoring for indications of HIV infection. Before these links were 

made, many people did not even know about the health centers. CARE’s integrated 

ECD model is promising because it does more than reduce a young child’s vulnerability and isolation, increase health status and enhance school readiness. The ‘‘5 

x 5’’ model also promotes women’s economic empowerment and girls’ education. 
15

How? Because so often women cannot work because they are responsible for child 

care, or girls are taken out of school to look after younger siblings. 

RECOMMENDATIONS FOR SUSTAINABILITY AND LONG–TERM IMPACT

There is broad consensus that, in order to optimize the U.S. government’s investment in the global response to HIV and AIDS, PEPFAR must be better focused on 

sustainability. Based on our extensive field experience with HIV and AIDS programming and our role as a PEPFAR implementing partner, CARE makes the following 

recommendations:

1. Address HIV and AIDS within a development framework. The Committee 

should provide PEPFAR with a long-term outlook and foster comprehensive 

approaches to HIV and AIDS by making ‘‘wraparound’’ truly effective.

2. Focus on the vulnerability of women and girls to HIV and AIDS. We should 

invest in comprehensive approaches that address the multiple factors that 

drive the vulnerability and low status of women and girls, and integrate HIV 

and AIDS responses with reproductive health and family planning.

3. Invest in scaling up evidence-based HIV prevention strategies. Ultimately, we 

must increase and re-balance funding to scale up comprehensive prevention 

efforts, while we confront the realities of HIV transmission with evidencebased strategies.

I will discuss each recommendation in further detail, grounding my observations 

in CARE’s field experience and recent expert analysis. 

1. Address HIV and AIDS within a development framework. 

PEPFAR’s current orientation—of rapid results, short-term funding, narrow focus 

and numeric outputs—is not well-suited to addressing the multi-faceted links between HIV and AIDS and development. Let me give you an example from CARE’s 

experience in Rwanda, where genocide and AIDS have produced large numbers of 

OVC. With three-year funding from the European Union, CARE set out (in 2003) 

to provide comprehensive care to OVC in communities affected by HIV and AIDS, 

especially child-headed households. From the outset, we wanted the approach to be 

sustainable, community-based and capable of responding not only to children’s material needs but also their psychosocial and protection needs. The model that 

emerged was of volunteer community mentors (Nkundabana)—organized into associations, recognized in their communities, trained and supported, and chosen by the 

children for their integrity—being parent figures, providing mentoring and counseling, facilitating access to basic services, and advocating for OVC needs and 

rights. The approach invested heavily in community participation and ownership, 

taking the time to cultivate a feeling of responsibility toward OVC, giving OVC the 

confidence and opportunity to articulate their own needs, and engaging Rwandan 

organizations in helping OVC claim their rights and recover from trauma. 

Our model remained flexible and open to change; it evolved considerably over 

three years, with many of the changes initiated by OVC or Nkundabana. The results 

have been very promising in terms of mitigating the impact of HIV and AIDS: OVC 

are more integrated into their communities; they have better access to schools, 

health care and nutrition; they are more secure from violence, especially girls vulnerable to sexual abuse; they know more about HIV and family planning; they have 

reclaimed property lost in ‘‘land grabs’’ to which OVC are typically vulnerable; and 

older OVC are earning incomes as a result of vocational skills and savings and loans 

groups. At the end of the project, 95 percent reported better relationships with community members and 96 percent that local authorities would look out for them if 

they had problems, major progress for a segment of the population generally facing 

widespread exclusion and marginalization. 

In 2005, we received PEPFAR funding to replicate the Nkundabana model and 

soon realized how challenging it was to align a comprehensive, community-oriented 

model with PEPFAR’s way of doing things. Short-term funding and pressure to meet 

numerical targets focused attention on implementing activities quickly and limited 

CARE’s ability to assure that this approach to caring for OVC was fully integrated 

within and owned by the community, so that it could be sustained over time. CARE 

is no longer a major implementing partner for PEPFAR’s OVC care and support 

interventions in Rwanda, but we did secure further EU funding to work with partners to continue developing the Nkundabana model and to replicate it in the northern part of the country. The pressure within PEPFAR to deliver quickly and on a 

large scale is in constant tension with the goal of sustainability. PEPFAR reauthorization must address this challenge by:

A. Articulating a long-term outlook for PEPFAR.
16

1This does not, in any way, translate to weaker accountability or negate the need for regular 

monitoring of results. 2 UNAIDS, 2006 Epidemic Update, p 4. 

3PEPFAR Implementation: Progress and Promise, Institute of Medicine, March 2007, p 7. 4 Bringing HIV Prevention to Scale: An Urgent Global Priority, Global HIV Prevention Working Group, June 2007, p 9. 

• Require long-term, integrated, multi-sectoral strategies for the U.S. government response to HIV and AIDS in each country. These strategies would position HIV and AIDS within the broader development setting and be aligned 

with the plans of national governments.

• Provide multi-year funding that fosters a sustainability mindset. Three-year 

funding commitments should be a minimum.

• Focus on achieving long-term impact rather than generating quick results.1

Impact measures must address social processes that underpin the social, cultural and economic transformations needed to disable the AIDS epidemic, to 

validate that our interventions are effective, and to hold all of us accountable. 

B. Making ‘‘wraparound’’ work in order to advance coherent, integrated programs.

• Ensure that there are other viable funding streams to wrap around PEPFAR. 

Funding for family planning, education, micro-finance and food security, for 

example—essential to integrate with an HIV and AIDS response—must be 

enhanced.

• Improve coordination among U.S. government agencies through stronger 

inter-agency planning, budgeting, and monitoring and evaluation.

• Harmonize USG plans and investments with those of national governments 

and other donors for maximum synergy and complementarity in the pursuit 

of shared goals. 

2. Focus on the Vulnerability of Women and Girls to HIV and AIDS. 

The face of the AIDS epidemic is female—and increasingly young. In sub-Saharan 

Africa, 60 percent of the people living with HIV and AIDS are women; and for each 

young man newly infected with HIV, three young women are infected.2 This not 

only reflects the acute vulnerability of women and girls to HIV and AIDS, but also 

the failure of the global response to address the complex factors that drive their vulnerability. Women are biologically more susceptible to contracting HIV and socially 

less able to negotiate safe sexual encounters. Far too many girls are coerced into 

first sex or forced into early marriages with older men. Far too many women are 

pressured into ‘‘survival sex’’ out of sheer poverty. When women are known to be 

HIV-positive, they are often blamed and ostracized, even though they so often contract the virus from their unfaithful husbands. When a family member is HIV-positive, women and girls shoulder the burden of caring for the sick. The property of 

AIDS widows is frequently expropriated by their in-laws. The multiple ways in 

which women are affected by HIV and AIDS lay bare their vulnerability due to social norms that relegate them to a subordinate status in relation to men. 

In identifying what it would take to shift PEPFAR toward sustainability, the IOM 

evaluation noted that ‘‘most of the factors that contribute to the increased vulnerability of women and girls to HIV/AIDS cannot be readily addressed in the shortterm’’ and recommended that PEPFAR focus on ‘‘factors that put women at greater 

risk of HIV/AIDS.’’ 3 The recent report of the Global HIV Prevention Working Group, 

of which I am co-chair, argues that an effective strategy would need to reduce women’s vulnerability by fostering women’s empowerment—including helping women secure rights to property and inheritance, increasing their economic independence, advancing universal education for girls, preventing sexual violence and developing new 

HIV prevention methods that women can control.4 Engaging men and boys, and 

shifting gender norms over time, is also vital. CARE endorses these recommendations. Our experience points to the need to address women’s vulnerability in comprehensive ways, focusing not only on their HIV-related needs but also on their ability to make independent decisions (e.g. accessing health services), their confidence 

to negotiate in relationships (e.g. with husbands, village chiefs, service providers), 

laws and institutions that protect women’s rights (e.g. in relation to property and 

inheritance rights) and opportunities to link women together to promote solidarity 

and collective action. 

In Kenya, CARE implements a PEPFAR-funded program that aims to prevent 

mother-to-child transmission (PMTCT) of HIV in Nyanza province, which has the 

highest HIV prevalence rate in the country (15 percent). This work began with a 

narrow focus on testing women and making ART available to mother and baby, but 

it is continuously becoming more comprehensive. As such, we believe it is a worthy 
17

5 Ibid, p 1. 

6 Ibid, p 1. 

7Stover et al. The Global Impact of Scaling Up HIV/AIDS Prevention Programming in Lowand Middle-Income Countries. Science. 2006: 311: 1474–1476. 

model for PEPFAR to evaluate more deeply. To prevent a child saved from HIV 

dying of a preventable diarrheal disease, CARE facilitated access to safe water systems. To deal with the reality that pregnant women who test HIV-positive often do 

not return for ART (out of fear of violence or stigma, or because she cannot afford 

transport), we organized support groups for HIV-positive mothers, mobilized communities against HIV-related stigma and linked women with micro-credit services. 

Since 2003, uptake of nevirapine at thirteen anti-natal clinics in Siaya district, 

CARE’s main focus area, increased from 35 percent to 94 percent. Recognizing that 

the most cost-effective PMTCT method is to avoid unintended pregnancy in the first 

place, the program is now linking with family planning services. 

We welcome the steps that the Office of the Global AIDS Coordinator (OGAC) has 

taken to address gender issues. OGAC now collects sex-disaggregated data, has five 

priority gender strategies, convenes an inter-agency Gender Technical Working 

Group, and has allocated $8 million toward gender-related initiatives. These are 

promising trends, and PEPFAR reauthorization should push for deeper impact on 

women and girls’ vulnerability by:

A. Advancing comprehensive programs that address the social, economic and 

cultural factors that enhance the vulnerability of women. Since the low status of women is itself a driver of vulnerability, women’s empowerment 

should be embraced by PEPFAR as a desired endpoint. Recognizing that 

transforming gender norms and relations is a slow process, such results 

must be pursued within long timeframes. Otherwise, we run the risk of 

doing more harm than good.

B. Integrating and linking HIV and AIDS and reproductive health programs, 

and strengthening efforts to reduce unmet family planning needs among 

HIV-affected women.

C. Developing mandatory operational guidance for country programs on gender-responsive programming. This guidance should help country teams and 

implementers conduct analysis, planning and evaluation to meaningfully integrate gender dimensions into all of PEPFAR’s work.

D. Investing in independent impact studies that provide a sharper sense of 

‘‘what works’’ (what gender interventions are most effective in impacting 

HIV outcomes in the long-term) and scaling up effective approaches for 

maximum impact. 

3. Invest in Scaling Up Evidence-Based HIV Prevention Strategies. 

Despite a six-fold increase in financing for HIV programs in developing countries 

between 2001 and 2006, the effort to reduce new HIV infections is faltering.5 For 

every patient who began ART in 2006, another six people were infected with HIV. 

Such results will not lead to success or sustainability. There is an urgent need to 

focus on comprehensive, evidence-based strategies and take those strategies to scale. 

Half of the infections projected to occur by 2015 could be averted, if the right interventions are focused on the right people at the right scale—and this degree of success is likely to disable the epidemic and push it toward long-term decline.6

I want to underscore the importance of thinking in terms of the right interventions, the right people and the right scale. We need to match our responses to the 

specific epidemiology of each country; there is no ‘‘one size fits all’’ solution and our 

mix of interventions should be quite different in generalized epidemics and concentrated epidemics, for example. Investing in prevention at the right scale is an 

enormously important factor, which has not received adequate attention. There are 

many barriers to scaling up, beginning with insufficient and uncertain funding. The 

scale up of funding for treatment, and the resulting steady increase in numbers of 

people on ART, demonstrates that dramatic progress that can be achieved, when political will is strong. Given the high need that remains, we must keep up the 

progress on treatment access even as we scale up comprehensive prevention efforts 

to a level that can halt the growth of the AIDS pandemic. Significantly ramping up 

HIV prevention spending now would not only avert half of the new infections projected to occur between now and 2015, but also yield net financial savings in terms 

of treatment and care costs avoided.7

In identifying what it would take to move PEPFAR toward sustainability, the 

IOM report noted that, ‘‘partly in response to legislative mandates, [PEPFAR] has 

supported some preventive interventions that are not firmly evidence-based [and] 
18

8 Institute of Medicine, p 6. 

9Stover et al.

addressed sources of HIV transmission in disproportion to their expected contribution to the ultimate goal of preventing new infections.’’ 8 PEPFAR’s approach to prevention of sexual transmission, symbolized by the abstinence-until-marriage earmark in the Global AIDS Act of 2003, has drawn both sharp criticism and ardent 

approval. CARE’s experience with the ABC approach is that U.S. government country teams implement the ABC approach unevenly, some allowing considerably more 

latitude for implementers than others. The result is that the heavy emphasis on AB 

and the polarization of the prevention debate into ‘‘AB versus C’’ often misses the 

reality that even a balanced ABC approach offers limited options to the most vulnerable people, especially women and girls; ultimately, it is the ‘‘ABC plus’’ approach 

that we must advance. 

We endorse the recommendations of the Global HIV Prevention Working Group, 

and call for a package of comprehensive prevention interventions—from HIV testing 

to condom promotion, from PMTCT to interventions for injecting drug users, and 

from behavior change to anti-stigma measures—to be fully scaled up in each focus 

country. PEPFAR reauthorization must invest in scaling up evidence-based prevention strategies by:

A. Funding the scale-up of comprehensive prevention efforts. CARE recommends that Congress assign universal access to prevention as PEPFAR’s 

highest priority and that it provide sufficient funds to ensure U.S. fairshare support to scale up prevention programming in focus countries and 

other affected low- and middle-income countries, as appropriate, to combat 

the AIDS pandemic.9

B. Tailoring prevention strategies to match the epidemiology of each country. 

This necessarily means removing arbitrary restrictions in order to allocate 

resources to areas where the largest number of new infections can be averted. CARE recommends that the PEPFAR reauthorization avoid budget allocations and restrictions such as the abstinence-until-marriage earmark and 

the anti-prostitution pledge requirement, since they tend to work against 

evidence-based prevention approaches being deployed in the most strategic 

manner.

C. Advancing an ABC plus approach to address underlying vulnerabilities. 

This includes confronting social norms that put women and girls at risk, 

as well as targeted efforts to prevent gender-based violence, enhance food 

and economic security, secure property rights and improve access to reproductive health services.

D. Deploying evidence-based strategies to curb HIV transmission in high-risk 

groups including sex workers, injecting drug users, men who have sex with 

men, and prisoners. In much of Asia and Eastern Europe, these groups account for the majority of new HIV infections. In order to have a global impact, PEPFAR must employ more effective, evidence-based strategies to 

prevent transmission among high-risk groups.

Mr. Chairman, Members of the Committee. You have a singular opportunity to 

make an extraordinary difference throughout the world by ensuring that millions 

of lives are saved and PEPFAR is even more effective over the next five years. I 

thank you for the opportunity to contribute to this important discussion. 

I would be pleased to answer any questions.

Mr. PAYNE. Thank you very much. Dr. Daulaire. 

STATEMENT OF NILS DAULAIRE, M.D., MPH, PRESIDENT AND 

CEO, GLOBAL HEALTH COUNCIL 

Dr. DAULAIRE. Thank you very much. And my particular appreciation to Chairman Lantos and Ranking Member Ros-Lehtinen for 

convening this important hearing; and to you, Congressman Payne, 

and Congressman Smith, for your leadership of the Africa Subcommittee and your work on global health broadly. 

I represent the Global Health Council, which is a membership organization made up of more than 400 organizations working in 

over 100 countries around the world, delivering healthcare services 
19

on the front lines. Our members work in HIV/AIDS, reproductive 

health, infectious diseases, maternal and child health, water and 

sanitation, nutrition programs, and the entire range of activities 

that go into making people living in the poorest corners of the 

earth healthier. 

Personally, I am a physician. I have spent the last three decades 

working in the arena of global health, both personally and also 

working on policy and advocacy. So I have seen this from many different sides. 

And over those three decades, there is no question but that the 

advent of HIV/AIDS on the scene a quarter of a century ago was 

one of the watershed marks in the history of global health. 

It was a slow and disappointing start in terms of the global response. But over the past decade, the attention that has come to 

bear, and in the past 4 years the establishment of PEPFAR has 

been a vitally important step forward, a final recognition and dramatic action which we strongly applaud. And we applaud this committee’s profound role in making that happen and supporting it on 

a bipartisan basis. 

But we are now at a point of looking at reauthorization of 

PEPFAR, or you are. We are here to help you, we hope. And I 

would say that, again, as a physician, we have been looking at how 

to get the emergency room up and running. That is, the President’s 

Emergency Plan for AIDS Relief. 

And at this point it is time to begin the transition to building, 

if you will, the community clinics that will keep people from coming 

into that emergency room. 

We recognize at this point that HIV will be with us, will be with 

the world, for a very long time to come, for generations to come. 

We have no cure. The most promising vaccine candidate last week 

was, sadly, found to be ineffective. And so as this committee looks 

at ways of establishing a long-term response—I am not taking 

away from the emergency aspect, but to make this something that 

the United States is in for the long haul, because that is our obligation—we need to start thinking about this as a chronic disease. The 

same way we think about diabetes and heart disease and cancer 

in this country. Something that we have to build comprehensive 

and integrated programs to address. 

Now, we have heard the word integration a number of times this 

morning. And often, something like that can become a buzz word 

that loses its meaning. But let me telling you from the standpoint 

of the practitioners and the implementers in the field whom I represent, integration is a profoundly important aspect of making 

things work. And I would urge this committee, as you look at reauthorization, to look at integration on four levels. 

First, internally. As Dr. Gayle has talked about, the integration 

between prevention, treatment, and care. 

Second, laterally. Integration with other U.S.-supported health 

programs. 

Third, nationally. In the countries where PEPFAR is working, 

working to support health systems and developing manpower who 

will be able to address these problems over the long term. 
20

And fourth, externally. Working closely with other programs that 

are engaging in addressing not only HIV/AIDS, but other critical 

health needs in the world. 

Now, we have heard several times today that we will never be 

able to treat our way out of this epidemic. And that is notably true, 

when we look at the fact that for every person who has been started on treatment, under PEPFAR and the Global Fund, six new people have become infected. Obviously, prevention has to be the hallmark of effective action. And I strongly endorse Dr. Gayle’s earlier 

testimony. 

Secondly, in terms of integrating across health programs. We recognize at this point, the people who are out there in the field, that 

HIV/AIDS programs cannot succeed on their own. And I believe we 

will be hearing from Dr. Mukherjee about some very specific aspects of that. 

In addition, better health can’t be accomplished without looking 

across the range of programs between HIV/AIDS, maternal and 

child health, family planning and reproductive health, control of 

other infectious diseases, and the building of health systems. 

And let me be specific. We have heard about the important work 

that has been done in terms of preventing infections of newborns 

with HIV. This is a preventable tragedy that occurs more than half 

a million times a year. PEPFAR addresses this through a program 

to test pregnant women and provide those who are HIV-positive 

with the drug Navirapane, which is a low-cost, highly effective 

intervention. This is a terrific medical intervention. And yet, even 

though it has been a priority under PEPFAR, throughout the world 

even now, most women are never tested for HIV. Only a small proportion of those who could benefit receive Navirapane. Only a small 

dent has been made in the number of infected children born in poor 

countries. And even less impact has been seen in overall child 

death rates. 

Now, this is not a criticism of PEPFAR; it is a reality of the difficult circumstances that we try to work in. And why is it? 

First, because women generally come to the healthcare system in 

the first place not for HIV care, so they don’t come to the HIV clinic. They come for routine family planning and maternal and child 

healthcare. Most of them don’t even know that they are HIV-positive. So unless the HIV services are deeply integrated with family 

planning and maternal and child health services, most who need 

them will never even know that they need them, much less get 

them. 

These women need help with more than just their HIV infections. Their first priority is for safe pregnancy and delivery. They 

and their newborns need to sleep under malaria bed nets. They 

need access to nutritious food. They need to know how they can 

delay, or even prevent, their next pregnancy, if they so choose. And 

their newborns, whether HIV-infected or not, still need basic newborn and child care. After all, most children who die, even most 

children dying as a consequence of HIV infection, die from diarrhea, pneumonia, malaria, and other common immunizable childhood diseases. Anti-retroviral drugs alone can’t save them without 

the child health services, which, sadly, are currently in some places 
21

withering on the vine, because resources and manpower are being 

redirected toward the single issue of HIV. 

When we look at these linkages, it becomes clear that we have 

to support the broader range—and in my written testimony I have 

provided some more details of what I would propose there. 

Thirdly, as I said, it is important to integrate nationally. And we 

will be hearing in a few moments about the vital importance of 

strengthening health systems and assuring an adequate supply of 

well-trained, well-supported, and well-motivated healthcare workers, from doctors down to community health workers. 

Now, this increased support is vital. We are delighted to see the 

dollar levels that are being talked about for reauthorization. But I 

want to stress that in this context of global health, this support 

must not come at the cost of other global health programs. It must 

come as a part of a broad support package. 

PEPFAR should not be, in our opinion, the U.S. Government’s 

global health platform. It is appropriately directed at HIV and 

AIDS. But the U.S. Government does need to build such a platform. And I look forward, Mr. Chairman, at a future point in having that discussion with the committee. 

We are delighted that the issue that is foremost on the minds 

and hearts of millions of people around the world has received the 

level of attention that it is now receiving from the United States 

Congress and this administration. We congratulate you on this, 

and we look forward to working with you in the future. 

Thank you. 

[The prepared statement of Dr. Daulaire follows:]

PREPARED STATEMENT OF NILS DAULAIRE, M.D., MPH, PRESIDENT AND CEO, 

GLOBAL HEALTH COUNCIL

Chairman Lantos, Ranking Member Ros-Lehtinen and members of the committee, 

thank you for holding this important hearing today on PEPFAR Reauthorization: 

From Emergency to Sustainability. I am Dr. Nils Daulaire, President and CEO of 

the Global Health Council, the world’s largest membership alliance of health professionals and service organizations working to save lives and improve health throughout the world. 

Before I begin my remarks, let me applaud you, Mr. Chairman and other members of the Committee, for your steadfast commitment and dedication to global 

health issues, and especially for your dedication to fighting HIV/AIDS. I congratulate you for your bipartisan work on H.R. 1298, the United States Leadership Act 

Against HIV/AIDS, Tuberculosis and Malaria. This historic legislation set the stage 

for an unprecedented U.S. Government investment in the fight against a serious 

global health challenge. The importance of this massive investment cannot be overstated; it has literally transformed the concept of what is possible in the realm of 

global health. On behalf of the Council’s 400 member organizations working in over 

100 countries across the globe, and the millions whose lives are improved by U.S. 

Government-supported global health programs, we thank you. 

The Global Health Council’s members include nonprofit service organizations, 

faith-based organizations, schools of public health and medicine, research institutions, associations, foundations, private businesses and concerned global citizens 

whose work puts them on the front lines of global health—delivering programs, 

building capacity, developing new tools and technologies, and evaluating impact to 

improve health among the world’s poorest citizens. Our members work on a wide 

array of issues, including of course HIV/AIDS, but also other infectious diseases, 

child and maternal health, family planning, water and sanitation, and health systems strengthening. 

I am a physician and have been personally engaged for more than three decades 

in the global effort to improve the health of the poor. When AIDS came on the scene 

25 years ago, few anticipated that it would grow to the worst pandemic of modern 

times, and the world’s initial slow response gave the virus a chance to establish its 
22

death grip on the lives of millions. But the past decade has been heartening to those 

of us who have taken on the challenge of building health programs and services in 

the forgotten corners of the world. U.S. leaders, as well as leaders from other countries and the U.N., notably UNAIDS through the sound leadership of Peter Piot, 

have recognized both the severity and the moral call of HIV/AIDS, and the response 

has been unprecedented. 

A signal accomplishment of this new century has been the partnership between 

the Bush Administration and a solid bipartisan majority of the U.S. Congress that 

moved the President’s Emergency Plan for AIDS Relief (PEPFAR) forward and 

made it the cornerstone of the largest prevention, care and treatment effort the 

world has ever seen. It is clear that PEPFAR has had some enormous successes over 

the last four years. Today you recognize that those successes need to be fully understood in order to build on them and to make them lasting. 

The things that have worked need to be reinforced, and those that haven’t worked 

so well need to be addressed. The reauthorization process provides us with an opportunity to examine ways to make this program more effective for the long run. 

To help provide constructive and informed input into the PEPFAR reauthorization 

process, the Global Health Council has for months now engaged a wide network of 

experts, implementers and advocates through the Global AIDS Roundtable and the 

more programmatic HIV Implementers Group. We look forward to working with this 

Committee over the coming months to ensure that the next generation of this program continues its forward momentum. 

This Administration’s commitment to the fight against the global spread of HIV/

AIDS has resulted in extraordinary accomplishments. Similarly impressive efforts 

have begun for malaria under the President’s Malaria Initiative (PMI). But one 

thing is clear to those of us who engage daily in delivering these services: While 

an emergency response focused on a single disease can have remarkable, short-term 

results, it will not succeed as a model for the long-term response that is necessary 

for reversing the HIV/AIDS pandemic. 

Early in his tenure, the President’s first Global AIDS Coordinator, Ambassador 

Randall Tobias, was asked about the inter-relationships between the HIV/AIDS response and other public health interventions such as maternal and child health, 

family planning, nutrition, clean water, and other diseases. His response was to acknowledge that these were important problems, but that his charter was to combat 

HIV/AIDS through the sharp lens of prevention, care and treatment. Congress had 

set very ambitious targets, he told us, and he had to stay completely focused on 

them. 

His point was understandable. But I believe that, in the long run, this was shortsighted, a mistake of first principles. Over the past few years, it has become very 

apparent that, in the long run, we cannot succeed in our efforts against HIV/AIDS 

without linking PEPFAR much more closely with these other interventions and with 

strengthening health systems more broadly. 

Let me take as an example the issue of newborn infection with HIV, a preventable 

tragedy that occurs over half a million times a year. PEPFAR addresses this 

through a program to test pregnant women and provide those who are HIV-positive 

the drug nevirapine, a low-cost highly effective intervention. This has been a priority program under PEPFAR. Yet throughout the world, most women are never 

tested for HIV, a small proportion of those who could benefit receive nevirapine, 

only a small dent has been made in the numbers of infected children born in poor 

countries, and even less impact has been seen on overall child death rates. Why is 

this? 

First, because women generally come to the health care system in the first place 

not for HIV care but for routine family planning and maternal and child health 

care. Most of them don’t even know they are HIV positive. So unless the HIV services are deeply integrated with family planning and maternal and child health services, most who need them will never even know they need them, much less get 

them. 

These women need help not just with their HIV infections. Their first priority is 

for a safe pregnancy and delivery. They and their newborns need to sleep under malaria bed nets. They need access to nutritious food. They need to know how they 

can prevent or delay their next pregnancy. 

And their newborns, whether HIV infected or not, need basic newborn and child 

care. After all, most children who die, even most children dying as a consequence 

of HIV infection, die from diarrhea, pneumonia, malaria and other common 

immunizable childhood diseases. Antiretroviral drugs alone can’t save them without 

the child health services that are currently withering on the vine because resources 

and manpower are being redirected towards HIV/AIDS. 
23

The current Global AIDS Coordinator, Ambassador Mark Dybul, understands this 

reality, and has taken steps to establish these linkages. I think he could use some 

help, and I believe that the Congress can provide that help by granting specific authority for, and even requiring, the Global AIDS Coordinator to link directly to these 

services and, when they are weak or inadequate, to support them directly with 

PEPFAR funds. Far from being a diversion of resources, this would assure that our 

HIV/AIDS dollars are spent most effectively. 

Should PEPFAR then be the platform for all basic health services or bear the programmatic burden for the full array of health issues facing communities in the developing world? No. The appropriate U.S. policy approach must encompass, but not 

be based upon responses to any single disease. 

I will return to specific thoughts on PEPFAR reauthorization in a moment. Let 

me offer you the bottom line here: While beyond the scope of this hearing alone, 

the U.S. Government ultimately needs a comprehensive strategy to guide its engagement in improving the health of the world’s citizens and, in turn, protecting the 

health of its own. This is my fourth appearance before Congress this year. I have 

testified about maternal and child health, malaria, tuberculosis and now AIDS. I appreciate the opportunity to share expert perspective on each of these topics, but 

budget line items and various agency authorities have dissected a single experience—health—into disparate funding, policies and programmatic approaches that 

undermine our ultimate goal: healthier individuals and families and therefore more 

stable and productive global communities. Investing in health is not just a humanitarian response. The returns on its investments are also seen in economies and 

sound political systems. With U.S. Government investments in global health on the 

order of $6 billion (with nearly $5 billion committed to AIDS alone), don’t we want 

to make the most of our investment? I have been at this for decades, and I can tell 

you with confidence that single-disease, single-intervention or any other siloed approach simply will not succeed. 

This hearing is about transitioning the U.S. response to the global AIDS crisis 

through PEPFAR from an emergency program to a sustainable one, because we recognize that the AIDS virus will be in our midst for generations to come. Our response to HIV/AIDS must now expand from a model designed to help get the emergency room up and running to one where the community clinic can successfully keep 

people out of the emergency room in the first place. 

Of course, HIV-affected people must have access to antiretroviral drugs, but no 

one can survive on drugs alone. Just like everyone else, people who are living with 

HIV/AIDS—especially those who have gotten drugs to keep their infections in 

check—need good nutrition, clean water, vaccines, pre- and post-natal care for mothers and children and prevention, care and treatment for at the other major health 

threats that they face. 

Let’s face it, we are in a struggle to beat HIV/AIDS for the long haul-just like 

our battles to overcome cancer and heart disease at home. Now that HIV/AIDS is 

treatable, it has become a chronic disease, and chronic diseases require functioning 

health systems, working every day. Clinics must be open, staffed and supplied—and 

that can’t be done just for HIV alone. Health providers must be trained, supervised, 

supported and paid—and no one dreams that this could be an AIDS-specific cadre. 

Ministries of health and non-governmental organizations alike must function 

smoothly and efficiently, with solid leadership and management skills—and these 

must be generalized skills because the systems they must support are necessary for 

each and every health intervention. 

This is why beating HIV/AIDS demands more than HIV-specific prevention, care 

and treatment programs operating in isolation from other global health interventions. This is why the delivery of all essential health care services through strong 

and efficient health systems is necessary for the fight against AIDS. This is why 

greater integration and coordination of PEPFAR programs with other global health 

programs and services is the single-most important step the U.S. can take right now 

to maximize the program’s effectiveness in the future. I call on Congress to make 

sure that this is supported and encouraged in your reauthorization bill. 

PEPFAR can and should be better integrated on four different levels:

• Internally between its own prevention, treatment and care programs;

• Laterally across other U.S. global health programs addressing issues other 

than HIV;

• Nationally through the strengthening of health systems and support of expanded health manpower in countries with high burdens of disease; and

• Externally through enhanced coordination between PEPFAR and other HIVand non-HIV specific programs managed by focus country governments and 

by other international donors. 
24

INTERNAL INTEGRATION

To date, PEPFAR’s programs have been separated into the categories of prevention, treatment or care, with the focus and lion’s share of funding largely on treatment. This approach has proven too rigid in some cases to effectively save lives. 

Those who are at high risk of contracting HIV need to know how to stay HIV free 

and what treatment options exist if they do become infected. Those who are HIVpositive need to have access to the full range of prevention methods in order to improve their own health and to protect the health of those around them. It remains 

fundamentally true that treatment for people who are HIV-positive still needs to be 

expanded, but as we find that for every individual treated there are six new infections, it is clear that we will never be able to treat our way out of this epidemic. 

Prevention and treatment programs must work together, and I strongly support the 

recommendations you have heard from Dr. Gayle. 

INTEGRATION AND COORDINATION ACROSS U.S. GLOBAL HEALTH PROGRAMS

Most people who are battling AIDS actually die from infections caused by other 

organisms who have found an open door due to HIV’s suppression of the immune 

system; these are called Opportunistic Infections (OI’s). Currently, tuberculosis (TB) 

kills about one-third of AIDS victims. Pregnant women who contract malaria are at 

greater risk of HIV infection and those who are HIV-positive are at greater risk of 

malaria. And as I have noted, most children dying with HIV die as a direct result 

of common childhood infections. 

By only addressing the HIV/AIDS-specific aspects of the health of a person with 

co-infections and multiple susceptibilities, PEPFAR is, in some ways, saving lives 

only to leave them vulnerable to death in short order from other causes whose effects could have been minimized or eliminated with a more thoughtful and thorough 

programmatic response. A more comprehensive view of the disease and the appropriate response is needed. PEPFAR programs must have explicit linkages between 

their services and those other critical global health programs that focus on other 

diseases and health conditions. 

You have already heard from Dr. Gayle concerning the ways in which CARE integrates HIV/AIDS programs with other health and development efforts. We are 

proud to have CARE as a member organization of the Global Health Council. Family Health International (FHI), another of our member organizations, has also demonstrated the positive impact of an integrated response. One such model addresses 

the close link between HIV prevention and reproductive health services. The model 

includes pre- and post-test counseling of family planning clients, rapid on-site HIV 

testing of family planning clients and family planning counseling to HIV positive 

clients. This includes counseling on diet, exercise, medical care and psycho-social 

support. It also integrated family planning into PMTCT sites. FHI’s research has 

shown that using this approach can avert almost 30% more HIV-positive births than 

just HIV counseling and testing along with nevirapine treatment. 

A number of Global Health Council members are engaged with RAPIDS—a 

PEPFAR funded project that covers 53 districts in Zambia to provide home- and 

community-based care for people living with HIV/AIDS and support for orphans and 

vulnerable children through a coordinated response. In this example of successful 

coordination across U.S. programs, USAID, CDC, DOD, Peace Corps and the State 

Department have developed an intense, integrated and coordinated response in 

which it funded various organizations to take on projects that cuts across all sectors. 

The project funds agriculture, economic growth, health, education and democracy 

while at the same time aiming to scale up prevention, treatment and care. As a result, thousands of people living with HIV in Zambia are accessing basic health and 

development services, and not just anti-retroviral therapy. 

When PEPFAR was first announced, it was with assurances that this funding 

would be additive to funds already in place for global health and international development efforts. Sadly, we are seeing instances, such as in Ethiopia, in which 

PEPFAR and PMI funds have increased, while maternal and child health funds 

have been significantly cut. Can the majority of that country’s women and children 

who are dying despite being HIV-free, and whose deaths could readily be averted 

with effective, proven, low-cost interventions, consider this a victory? 

STRENGTHENING HEALTH SYSTEMS AND BUILDING HEALTH MANPOWER

HIV/AIDS has taken weak health systems in the most highly afflicted countries, 

particularly those in sub-saharan Africa, and stressed them to the point of collapse. 

A major contribution of PEPFAR was revealing the utterly desperate conditions 

of the world’s national health systems. Once money and resources began to flow, we 
25

quickly realized that we lacked the trained professionals to delivery life-saving 

interventions; we lacked the management systems to implement programs and handle large infusions of resources—nearly every link in the health system left something to be desired. Weak health infrastructure and lack of an adequate human resource supply in developing countries limit the ability to support the integration and 

coordination of HIV/AIDS services. 

While there is much to be done, perhaps the most pressing issue is the supply, 

type and training of health workers, particularly in the areas of expanding prevention services and detecting opportunistic infections. As the Institute of Medicine 

(IOM) recommends, PEPFAR must contribute to strengthening health systems and 

adequately train and support critically needed new health workers. 

EXTERNAL COORDINATION BETWEEN PEPFAR AND NON-U.S. HIV- AND NON-HIV

PROGRAMS

Coordination is absolutely necessary within programs of the U.S. Government. It 

is also essential with the governments of focus countries if we are to continue to 

build upon PEPFAR’s successes. According to the IOM’s report on PEPFAR, country 

teams ‘‘have been largely successful in aligning their plans’’ with a recipient country’s national HIV/AIDS strategies. Serious concerns remain, however, about ensuring that the siren call of available PEPFAR resources doesn’t result in situations 

where national HIV/AIDS strategies become seriously misaligned in proportion to 

countries’ specific disease burdens. 

When lives are at stake every dollar has to count. The U.S. Government also must 

take care to chart whether other public or private donors are investing in the same 

kinds of programs and in the same places as PEPFAR so that duplication—or worse, 

destructive competition—is avoided. 

Any discussion about vital coordination between PEPFAR and other HIV/AIDS efforts is incomplete without mention of the other cornerstone of the global response 

to this pandemic: the Global Fund to Fight AIDS, TB and Malaria. Early years saw 

aspects of unfortunate competition between PEPFAR and the Global Fund. I applaud Ambassador Dybul for his efforts to assure closer coordination and cooperation with the Global Fund, and encourage efforts to assure that this continues and 

is expanded, since each of these mechanisms has its own particular strengths and 

advantages. 

Successful multi-donor coordination on HIV/AIDS programs is not only possible, 

it makes for better programs. In Malawi, the UK’s Department for International Development, the Global Fund to Fight AIDS, TB and Malaria and Malawi’s Ministry 

of Health together designed the Emergency Human Resource Plan to build human 

resource capacity to address the severe HIV/AIDS crisis in the country. This joint 

planning and coordination helped Malawi to double its output of nurses in just three 

years and increase pre-service training for doctors. The strategic coordination avoided duplicative efforts, allowing the program to address a wide range of problems related to health systems. 

LOOKING FORWARD

Even with its remarkable accomplishments over the past four years, PEPFAR 

faces an uphill battle against a virus that manages to stay ahead of the world’s best 

efforts to defeat it. Just last week we heard about the failure of what had been considered our most promising vaccine candidate. No doubt, more disappointments will 

follow. This will be a long struggle requiring persistence and patience. 

As PEPFAR evolves with Congress’s oversight, a number of issues must be addressed. First, the structure of U.S. global health assistance must be seriously reviewed and, I would recommend, redesigned. Each agency currently working as a 

part of the U.S. global AIDS response has a separate funding and procurement 

mechanism, different benchmarks for reporting, and different targeted communities. 

Under the current model, coordination and integration of HIV/AIDS is more difficult 

than it needs to be. Congress should take steps to correct this. 

Congress must also assure that health systems and health manpower development are front and center in expanded efforts to address HIV/AIDS and other major 

causes of ill-health and death in highly affected countries. 

Finally, the U.S., other donors and national governments must take under serious 

consideration the financial implications of a sustainable response to global AIDS, 

specifically, and basic health more broadly. While U.S. funding for global AIDS grew 

from $125 million in 1997 to $5.4 billion in 2007, it still remains below the levels 

needed for fully scaling up prevention and treatment in the focus countries, much 

less the need for HIV/AIDS services in non-focus countries where millions of people 

are infected or at-risk. Treatment costs will rise with the need for second-line drugs 
26

and HIV-positive individuals living longer and requiring a wider array of health 

services. Effective and widespread prevention services will add significant costs. 

This need for expanded funding will continue from a finite pool of resources. Still, 

the funding currently available for global AIDS programs dwarfs the U.S. investments currently made in other global health programs. For example, USAID’s child 

and maternal health and reproductive health accounts have remained at around 

$360 million and $400 million a year respectively, and yet three times as many children and women die globally each year from non-HIV related causes than from 

AIDS. Resource constraints as well as policy restrictions have impeded the successful ‘‘wrap around’’ of non-HIV services with HIV services. 

Increased support for global AIDS programs must not come at the expense of 

other global health programs if we are to achieve both the goal of establishing an 

effective HIV/AIDS program and the goal of building comprehensive and efficient 

national approaches to all major global health threats. 

CONCLUSION

The President’s Emergency Plan for AIDS Relief may be relatively new, but the 

fight against the global spread of HIV/AIDS is not. We have reached a point where 

the emergency response is still necessary but no longer sufficient in our fight 

against HIV/AIDS. HIV/AIDS is intricately linked with other diseases. To effectively 

combat this pandemic, we must expand our response, and a comprehensive approach to global health in developing countries is needed to do that successfully. 

Today, I have proposed steps that could be taken in the near future to strengthen 

PEPFAR by better integrating PEPFAR services internally, across U.S. global 

health programs, with national health systems, and with external partners addressing HIV/AIDS in the developing world. We can improve upon the lessons learned 

through PEPFAR to improve our global AIDS response and reverse the HIV/AIDS 

pandemic. 

In the long term, I urge Congress and the Administration to also consider the role 

of PEPFAR in the context of developing a comprehensive U.S. strategy for addressing all critical global health issues. The Global Health Council and our members 

stand prepared to help address the realities in which a third of the world’s people 

live—and in which a disproportionate number die. 

Thank you again for the opportunity to testify before you today. I welcome your 

questions.

Mr. PAYNE. Thank you very much. Dr. Mukherjee. 

STATEMENT OF JOIA S. MUKHERJEE, M.D., MPH, MEDICAL DIRECTOR, PARTNERS IN HEALTH, ASSISTANT PROFESSOR OF 

MEDICINE, HARVARD UNIVERSITY 

Dr. MUKHERJEE. Thank you, Congressman Payne. I would like to 

thank Chairman Lantos, Ranking Member Ros-Lehtinen, and the 

members of this Committee on Foreign Affairs, and particularly 

Mr. Payne and Mr. Smith for their leadership on the Africa Subcommittee. 

I actually am here today representing Partners In Health, a nongovernmental organization for which I have served as the Medical 

Director for 8 years. Partners In Health has medical projects in 

Rwanda, Lesotho, Malawi, Haiti, Peru, Russia, and Mexico, as well 

as an HIV program in the United States. 

We are a PEPFAR-recipient organization, particularly in Haiti, 

where we are receiving money directly from PEPFAR. 

I want to talk specifically about my experience as the Medical Director of Partners In Health, and also as a clinician who works in 

these resource-poor settings. 

For the leading infectious global killers—HIV, TB, and malaria—

most experts agree that care should be delivered in the public sector and provided as a public good, rather than a commodity. Yet 

the public sector is woefully, inadequately resourced for the provi-
27

sion of basic health services, let alone the care of complex chronic 

diseases. 

The economic structure of post-Colonial Africa was based on 

loans from the World Bank and the International Monetary Fund. 

With these loans came conditions called structural adjustment. 

The purpose of these programs—structural adjustment—was to 

minimize government spending, thought to be bureaucratic, inefficient, and corrupt; and to, rather, invest money in the private sector, ostensibly to move these countries to market economies. 

Whether this concept, these structural-adjustment programs resulted in movement toward market economies is not for me to 

judge. In the words of the Star Trek’s Dr. Bones, ‘‘I am a doctor, 

not an economist.’’ But I can assure the members of this committee 

that this strategy, these structural-adjustment programs, resulted 

in the massive disinvestment in the health and education sectors, 

leading poor countries to have per capita health spending on the 

order of $2 to $5 per year. This health budget includes public sector 

employee compensation, money for essential medicines, and the 

building and maintenance of health infrastructure. 

To compensate for this woefully inadequate funding for health, 

user fees were imposed at the behest of the Bank and the International Monetary Fund as a cost recovery mechanism to fund the 

health sector. But in extremely poor, often non-cash economies, 

such fees serve as an enormous barrier to care. 

The confluence of these factors—underpaid staff, poor infrastructure, a lack of essential medicines and supplies, and prohibitive 

user fees—result in an oft-seen and grotesque sight: Public clinics 

that stand empty in the worst epidemic in the history of mankind. 

Equally tragic are countries such as Malawi, where there are no 

user fees and clinics are full but totally dysfunctional; lacking access to the tools of their trade, and able to do no more than minister over the dying, despondent health professionals have fled 

their country to work in the United States and Europe, leaving 

only 350 Malawian physicians to care for a population of 16 million. 

AIDS has not syphoned money away from these health systems. 

There is no money to syphon. 

Let me illustrate with an example of my work, and the work of 

Partners In Health, an NGO affiliated with Harvard Medical 

School and the Harvard School of Public Health, the strategy that 

we have used to strengthen health systems with money for HIV. 

Partners In Health was one of the first programs to provide highly active anti-retroviral therapy free of charge in a research-poor 

setting. In Haiti, where we had worked since 1983, we were able 

to successfully use the AIDS cocktail in 1998, just 2 years after it 

was available to treat patients in the United States and Europe. 

All of those patients, carried in on stretchers then, are still alive 

today. Not only are they alive, but they are living well; they are 

farming their fields, and they are caring for their children. This 

was a small initiative, only 60 patients between 1998 and 2001. 

But when multi-lateral and bilateral monies for AIDS treatment 

became available, we made the conscious decision that in order to 

get these lifesaving medicines and comprehensive programs, in-
28

cluding prevention and care, to all of those who needed them, we 

would have to deliver this care through public clinics. 

In the town of Hinche, Haiti, the national HIV/AIDS program 

called for three people in the public clinic to be trained in the preand post-test counseling of HIV. This town has a population of 

70,000, and had both a hospital and an outpatient clinic which 

stood empty. The first time I visited, they had seen 10 patients in 

1 day, and there were three inpatients in a 60-bed ward. 

Over the first year of HIV testing that was done with PEPFAR 

and Global Fund monies, only 43 cases of HIV were found, in a 

town that we anticipated 1500 people were in need of antiretroviral therapy. 

Two things about this example were striking. First of all, the low 

rate of uptake of testing. Secondly, the fact is that those 43 percent 

of people who were positive were 25 percent of all those tested. 

Through the entire year, only 176 people came forward for HIV 

testing. Some said this was due to stigma, others to voodoo and 

witchcraft; but what we knew is that the health system was not 

serving the people who lived in the town of Hinche. And they had 

absolutely no reason to think if they came to this clinic, they would 

get care. 

The reality is that in poor countries, people come to clinics because they are ill, not because they want to know their HIV status. 

Seeing this situation in the town of Hinche prior to the arrival of 

funds from PEPFAR to actually provide programmatic support 

rather than just testing, we realized that this program, these HIV 

programs, would only work if they were integrated within primary 

healthcare. A full general clinic is the best place to find HIV cases, 

to say nothing of the fact that the availability of general health 

services will have a far bigger impact on the health of the community. 

With our PEPFAR monies, Partners In Health supported the 

Ministry of Health clinic in Hinche, including refurbishing wards, 

providing essential drugs and supplies, steady power, telecommunications, and improved health worker salaries. We worked with the 

government to waive user fees for all patients with HIV, tuberculosis, for all children under five, for all pregnant women, and 

minimized user fees for other patients. 

The ministry hired new clinical and administrative staff, which 

we worked with to train. We increased the compensation of health 

workers so that they could spend their full day in clinic, and did 

not have to supplement their salary by having a private chamber. 

We trained a cadre of community health workers to perform active 

case finding for vulnerable families, to deliver HIV and TB treatment in the home, and to provide psycho-social support to patients. 

Needless to say, the clinic, with this bolstered support, had a 

skyrocketing rate of utilization of services. Today that very clinic 

sees 300 patients a day, and performs 600 HIV tests per month. 

Of the 8,500 tests that were performed last year, 5 percent were 

positive, meaning that HIV testing is now being used as a screening test, and we can provide prevention and education about abstinence, fidelity, and condom use to those people who are not yet infected. 
29

Today, more than 1,000 people are on anti-retroviral therapy in 

Hinche, and are followed by the Ministry of Public Health; and 

more than 400 people a year have been diagnosed and treated and 

cured from tuberculosis. 

The whole system, let alone AIDS case detection, treatment, and 

prevention, has been strengthened as a result of this funding for 

AIDS. 

In the context of this program implementation, we must move 

from emergency relief to long-term sustained commitment, to creating programs that are locally run and managed. To develop an 

adequate public-sector response to the challenge of the HIV/AIDS 

pandemic, we should work together with the public health sector 

to strengthen these systems overall. 

It is important to adequately train, retain, and compensate workers. Yet offices, country offices of PEPFAR still hold to the constraint that is rooted in the United States Foreign Assistance Act, 

that PEPFAR money cannot be used to compensate public-sector 

workers. This is simply not true. 

Currently, many PEPFAR-funded projects in the field are indeed 

providing salary support to public-sector workers involved in delivering AIDS care. Some experts estimate that 20 percent of 

PEPFAR funds are spent for the support of public sector, including 

salary. 

However, it is often the case that interpretations of the U.S. Foreign Assistance Act locally result in prohibitions on public-sector 

spending. Donors, NGOs, universities, and governments must work 

together to build sustained public health infrastructure and it is 

imperative that the responsibility for these programs be transferred to the public sector. 

There are more than 6–7 million people today who need antiretroviral therapy, and fewer than 3 million of them are receiving 

it. The setup phase of PEPFAR has indeed been successful. Our efforts and the efforts of the U.S. Government have been laudatory. 

But with the White House’s announcement of $30 billion for the 

PEPFAR reauthorization, and a target of only 500,000 new people 

receiving treatment in 5 years, PEPFAR will hardly have the visionary impact that was planned at its inception, and that has 

characterized its record to date. 

With these small targets, we are not building. We are simply 

sustaining work that is less than half done. In the next 10 years, 

with the goal of attaining universal access to HIV care and treatment, 10–12 million people will need to be started on antiretroviral therapy. Given that the GDP of the United States is fully 

one third of the world’s total resources, it is reasonable to expect 

the United States to support one third of the cost of systems to deliver treatment to these patients. This indeed was the goal of 

PEPFAR in its first inception: Targeting the U.S. resources to cover 

the cost of treating 2 million patients in the first 5 years. 

For the reauthorization of PEPFAR to continue in this generous 

and fair vein of 33 percent of the global AIDS commitment, we 

would need to cover the cost of 4 million people in treatment, not 

2.5 million, as currently proposed. To do this will take 50 billion, 

not 30 billion, U.S. dollars over the next 5 years. 
30

1Pablo Gottret & George Schieber, Health Financing Revisited: A Practitioner’s Guide (The 

World Bank 2006). 2World Health Report 2006: Working Together for Health (WHO, Geneva, 2006). 3http://www.unicef.org/infobycountry/lesotholstatistics.html Accessed September 18, 2007. 4http://www.unicef.org/infobycountry/malawilstatistics.html Accessed September 18, 2007

Today we have a choice that will clearly shape the global epidemic and the view of the generosity and fairness of the United 

States throughout the world. I urge you to build on the successes 

of PEPFAR, and to use the AIDS crisis to examine and address the 

illness and suffering throughout the world; not to preserve the first 

5 years of PEPFAR in the museum of unrealized possibilities, but 

rather as the beginning of a movement to strengthen health systems as a response to combat the worst epidemic in the history of 

mankind. 

Thank you. 

[The prepared statement of Dr. Mukherjee follows:]

PREPARED STATEMENT OF JOIA S. MUKHERJEE, M.D., MPH, MEDICAL DIRECTOR, PARTNERS IN HEALTH, ASSISTANT PROFESSOR OF MEDICINE, HARVARD UNIVERSITY

HEALTH SYSTEMS STRENGTHENING AND THE AIDS PANDEMIC

The long-awaited availability of money for HIV prevention, care, and treatment 

in resource-poor settings has resulted in the real possibility of stemming the enormous death toll of HIV. However, due to decades of health system impoverishment, 

sickness and death among all cadres of workers due to HIV, and the flight of educated people from the developing to the developed world, there are few trained 

health professionals who can implement and sustain these large scale programs. 

This situation has been called the ‘‘healthcare worker crisis.’’ Yet to proffer the simple equation—‘‘AIDS money is greater than the capacity of professionals to use it’’— yields just a pinhole view of a much larger landscape. In fact, the AIDS pandemic 

has done nothing if not lay bare the fact that health systems—in terms of personnel, 

equipment, medicines, and physical infrastructure—in many developing countries 

were never adequate to address the basic primary health care needs of the population , let alone address a new, chronic, infectious disease—AIDS and its fueling 

of the tuberculosis pandemic. People in poor countries understand this. In Rwanda, 

our patients offer the phrase ‘‘imboni ibibazo’’—as a description of the AIDS pandemic—a lens through which we see reality and the larger context. 

It is to this larger context to that AIDS has drawn our focus: developing countries 

bear 90 percent of the global burden of disease armed with only 20 percent of the 

world’s GDP and 12 percent of the world’s health expenditures to combat this burden.1 Africa is particularly hard-hit, bearing fully one-quarter of the world’s disease 

burden with 3 percent of the global health workforce, who are paid less than 1 percent of global health expenditures.2 With such paltry resources available in these 

settings, how do people get care? The answer is that they do not. For this and many 

other reasons, life expectancy in Lesotho is 35.1 years (compared to 76.7 years in 

Cuba);3 in Rwanda,203 children per 1,000 die before their fifth birthday (compared 

to 8 per thousand in the United States) and in Malawi, 1800 women die in childbirth for every 100,000 live births (as compared with 2 in the Sweden).4 These rates 

are not unique across the continent. Some of this morbidity and mortality is AIDSrelated, but much of it can be traced to inadequate health systems. 

When people in resource-poor settings do access health care, approximately 60% 

of all health expenditures are out-of-pocket payments to private pharmacies or clinics. For the leading infectious global killers—HIV, TB, and malaria—there is no 

question that care should be delivered within the public sector and provided as public goods rather as commodities; the control of tuberculosis, an airborne disease, has 

long been seen as a public good. Yet the public sector is absolutely inadequately 

resourced for the provision of basic health services, let alone chronic care for complex diseases. The majority of foreign aid directed to post-colonial African countries 

took the form of conditioned loans that were spent building market economies rather than investing in the public sector. These structural adjustment programs resulted in massive disinvestment and neglect of the health and education sectors. 

National health budgets were set at shockingly low levels, on the order of $2–$5 US 

per capita, and included limits on the number of and compensation for public employees as well as little money for essential medicines or building and maintenance 
31

5The negative impact World Bank and IMF macroeconomic structural adjustment policies was 

compounded by poor governance decisions, corruption, and misplaced spending priorities in 

many developing countries. 6http://www.unicef.org/infobycountry/haitilstatistics.html. Accessed September 18, 2007. 

of health infrastructure. Countries subjected to these fiscal constraints had few options for responding to escalating public health needs.5 User fees for health services 

were imposed at the behest of the World Bank and the International Monetary 

Fund. But in extremely poor, often non-cash economies, such fees serve as an enormous barrier to accessing care. The confluence of inadequate numbers of underpaid 

staff; poor infrastructure; a lack of medicines and supplies; and prohibitive user fees 

result in an oft seen and grotesque sight: public clinics standing empty in the midst 

of the worst epidemics in the history of mankind. Equally tragic are countries such 

as Malawi where there are no user fees for health care and clinics are full but completely dysfunctional. Lacking access to the tools of their trade and able to do no 

more than minister over the dying, despondent health professionals have leave and 

their country to work in Europe or the United States leaving only 350 physicians 

to care for a population of 16 million. 

New investments in global health, including the President’s Emergency Plan for 

AIDS Relief (PEPFAR), have given us the opportunity to treat and prevent HIV in 

resource-poor settings. Monies are available for drugs, for laboratory tests, and for 

prevention programs. But can and should new monies have a wider impact, beyond 

simply getting AIDS patients onto treatment? The answer is yes. Unequivocally, 

yes. However, the money must be used strategically—not just to fund ‘‘vertical’’ HIV 

programs (clinics and services that provide care for only one disease such as TB or 

HIV) but to support the rehabilitation and bolstering of public health systems. A 

commitment to primary health is critical, as HIV programs do not work in a vacuum: the majority of people presenting to clinic, especially in rural areas, come because they are sick, not because they want to know their HIV status. Health facilities must be accessible, well-stocked, and reliable, providing decent diagnosis and 

treatment of common diseases, before widespread HIV testing can occur. 

Let me illustrate with an example from the work of Partners In Health, an NGO 

affiliated with Harvard Medical School and the Harvard School of Public Health. 

PIH was one of the first programs to provide antiretroviral therapy free of charge 

in a resource-poor setting. Haiti, where we had been working since 1983, is the 

poorest country in the western hemisphere and also has the highest HIV, TB, and 

malaria prevalence and maternal and child mortality rates; life expectancy hovers 

around 52 years.6 Despite these grim statistics, we were able to successfully acquire 

medicines and launch comprehensive AIDS treatment efforts just two years after 

antiretroviral drugs became available in the first world. Our initial successes were 

bolstered by the advent of multilateral and bilateral monies for AIDS treatment, 

and in 2002 PIH began to expand its services throughout central Haiti by 

partnering with Ministry of Health clinics and hospitals. 

In the town of Hinche, Haiti, the national HIV/AIDS plan called for three people 

in the public clinic to be trained in pre- and post-test counseling for HIV. The town 

is the capital of the Central Department of Haiti and is home to about 70,000 people. Hinche has a hospital and outpatient clinic, both of which stood nearly empty 

when we first visited. The clinic was seeing 10 patients per day, and the hospital 

had 3–6 inpatients in its 60-bed facility. In the first year of the testing initiative, 

only 43 cases of HIV were found—about 25% of the 176 people tested. 

Two things about this example are striking. First of all, it was estimated that a 

minimum of 1,500 people were living with untreated HIV in the area; therefore, 

identifying only 43 new cases is appalling. One would think that the patients would 

be breaking down the barricades, since it was widely known that antiretroviral therapy was available free of charge. Second, the prevalence of AIDS in central Haiti 

is 2–4%. If 25% of the tests performed were positive, this is an indication that the 

test was not being offered broadly, as a screening tool, but, instead, was being offered only to those patients suspected to be infected. Broad screening is important 

because it offers avenues for intervention through prevention education. It also allows for earlier detection—and thus treatment—of HIV. 

Recall that PIH had committed to partnering with the public sector in scaling up 

its work with the advent of Global Fund and PEPFAR monies. Seeing the situation 

in the town of Hinche prior to our arrival was instructive: we realized that AIDS 

programs would only work if they are integrated with primary health care. A full 

general clinic is the best place to find HIV cases, to say nothing of the fact that 

the availability of general health services will have a far bigger impact on the 

health of the community. 
32

With these lessons in mind, PIH’s support of the facilities in Hinche included refurbishing wards; providing essential drugs, supplies, and steady power; and improving telecommunications capacity. We waived user fees for HIV patients, TB patients, children under 5, and pregnant women and minimized fees for all other patients. We hired and trained new clinical and administrative staff and also increased the compensation of existing Ministry of Health staff. We trained a cadre 

of community health workers to perform active case finding of vulnerable families, 

deliver HIV and TB treatment in the home, and provide psychosocial support to all 

patients. Needless to say, the bolstered clinic, coupled with increased community 

support, resulted in skyrocketing utilization of services. Today the Hinche clinic sees 

300 patients per day and performs 600 HIV tests per month. Out of the 8,500 tests 

performed last year, only 5% were positive. More than 1,000 HIV-positive patients 

in Hinche, more than a third of whom are on ART, are now being followed by PIH. 

More than 400 patients have been diagnosed and treated for tuberculosis. The whole 

health system, let alone AIDS case detection and treatment, has been strengthened 

as a result of interest in and funding for AIDS. More recently, we constructed an 

on-site training center that has become a local, national, regional, and international 

hub for training on the provision of AIDS care in resource-poor settings; at least in 

rural central Haiti, the healthcare worker crisis is no longer a pressing issue for 

us. We know that success is possible, but the constraints are many. We are convinced 

that health systems strengthening is the only way to address not only the AIDS and 

TB pandemics but other health crises as well. In the context of HIV program implementation, we must move from ‘‘Emergency Relief’’ to long term, sustained commitment to creating programs that are locally run and managed. To develop an adequate public sector to respond to the challenge of the AIDS pandemic should be the 

goal of such assistance. However, to assist in building a public sector response, it 

is important to adequately train, retain and compensate health workers. Yet, country offices of PEPFAR still hold to the constraint, rooted in the Foreign Assistance 

Act, that PEPFAR monies cannot be used to compensate public sector workers. This 

is not true. Currently, many PEPFAR funded projects in the field are, indeed, providing salary support for public sector workers involved in delivering AIDS care. 

Some experts estimate that 20% of the PEPFAR budget is spent on support for the 

public sector, including salaries. However, it is often the case that the interpretations of the Foreign Assistance Act result in prohibitions on public sector support. 

Thus, in a multitude of cases, PEPFAR money funds the private, NGO sector resulting in the development of parallel health systems—charity and public and further 

impoverishing the public health system which is the most sustainable and widespread means of delivering health care to the poor. If donors, NGOs, universities, 

and governments are to work together to build or rebuild sustainable public health 

infrastructure, it is imperative that the responsibility for and the funding of these 

programs be gradually moved to the public sector. African leaders signed a pledge 

in Abuja, Nigeria in 2001 to commit 7% of their GDP to health; in a poor country 

such as Rwanda that is experiencing a growing economy, it is possible to imagine 

that, with time, the government will be able to cover much of the cost of a functional public health system. In countries like Haiti, however, 7% of GDP will not 

soon cover the cost of a functional health system. International donor money must 

help put in place the systems that can address not only HIV but also other diseases 

and primary health goals. Why not use the AIDS crisis to build something that will 

be sustained for generations to come? 

In its first years, much of PEPFAR money was allocated to non-governmental organizations (like mine) with the notion, perhaps, that governments are inefficient 

or corrupt. The money was, based on the title of the program, geared toward and 

emergency. Today, programs are established, money has been well used, and people 

all over the world are receiving care within government driven national plans. It 

is time to shift the focus of aid to a second phase where our response is made sustainable. With nearly 3 million people on HIV treatment in resource-poor settings 

around the world, it is clear that the public sector must shoulder the responsibility 

for treating and monitoring this and other chronic diseases and fully ensconcing 

AIDS treatment into the delivery of primary health care services. 

To close, I’d like to make a few general comments related to PEPFAR to improve 

its overall impact and effectiveness in the next phase. We applaud the new financial 

resources that have been dedicated to helping address the HIV/AIDS crisis thus far. 

The achievements which have made in getting more patients into AIDS prevention 

and treatment programs are laudatory. However, it behooves us now to be more ambitious. There are more than 6 to 7 million people today alone who need ART and 

fewer than 3 million of those are receiving it. The set up phase has been successful, 

but if we keep funding at this level and targets for patients on treatment low, we 
33

are not building; we are sustaining work that is less than half done. In the next 

ten years, with the goal of attaining universal access to treatment, 10–12 million 

people will need to be started and maintained on treatment. The PEPFAR reauthorization announcement from the White House only included a target of an additional 

500,000 patients to be put on treatment for the next five years. Given that the GDP 

of the US is fully 33% of the world’s total resources, it is reasonable to expect the 

US to support 33% of the cost of systems to deliver treatment to these patients. 

This, indeed, was the goal of PEPFAR in its first iteration, targeting the US resources to cover the costs of treating 2,000,000 patients in the first five years. For 

the re-authorization of PEPFAR to continue in this generous and fair vein of 33% 

of the global AIDS commitment would mean to cover the cost of 4,000,000 people 

in treatment end of 10 years, not 2,500,000 as currently proposed. The target of 

500,000 additional people in treatment and only 30 billion USD proposed for the 

second five years is less than level funding the United States’ most successful international aid program. Thus, to meet the needs of the countries suffering, hold up 

the US share of international aid and build and sustain health systems to deal with 

this crisis, at least 50 billion USD over the next five years is necessary. 

Today we have a choice that clearly sculpts the global epidemic and the view of 

the generosity and fairness of the United States throughout the world. I urge you 

to build on the successes of PEPFAR, to use the AIDS crisis to examine and address 

the illness and suffering throughout the world and not to preserve the first five 

years of PEPFAR in a museum of unrealized possibilities in addressing for the long 

term, the worst epidemic in the history of mankind.

Mr. PAYNE. Thank you very much. Dr. Hearst? 

STATEMENT OF NORMAN HEARST, M.D., MPH, PROFESSOR OF 

FAMILY AND COMMUNITY MEDICINE AND OF EPIDEMIOLOGY AND BIOSTATISTICS, UNIVERSITY OF CALIFORNIA, 

SAN FRANCISCO (UCSF), SCHOOL OF MEDICINE 

Dr. HEARST. Thank you, Mr. Chairman. We are here today to 

talk about making PEPFAR sustainable. And the key to sustainability must be prevention. 

As we have already heard this morning, we cannot treat our way 

out of this epidemic. Despite our best efforts, at least five people 

are being infected with HIV in Africa for every one that we are 

starting on treatment. And, treatment or not, these people will 

eventually die of AIDS. 

For prevention, it is fundamental to distinguish between concentrated and generalized HIV epidemics. These are different situations that require very different strategies. In most countries, HIV 

is mainly transmitted in high-risk settings, including men who 

have sex with men, injecting drug users, and commercial sex, so 

that is where you need to do prevention. 

But in generalized epidemics, transmission is widespread in the 

heterosexual population, so you can’t focus only on high-risk 

groups. 

Just a few countries in Eastern and Southern Africa have this 

pattern. But these countries, because of their very high infection 

rates, account for most of the world’s HIV infections. And most 

PEPFAR priority countries have generalized epidemics, which is 

why they were chosen as priority countries in the first place. 

Five years ago, I was commissioned by UNAIDS to conduct a 

technical review of how well condoms have worked for AIDS prevention in the developing world. My colleagues and I collected 

mountains of data, and here is what we found. 

First, condoms are about 85 percent to 90 percent effective for 

preventing HIV transmission for individuals who use them all the 

time. We then looked at whether condoms have been successful as 
34

a public health strategy, something very different from individual 

effectiveness. Here we found good evidence for effectiveness in concentrated epidemics. 

For example, condoms helped control HIV among gay men in 

places like my home town, San Francisco, and epidemics driven by 

commercial sex in places like Thailand. 

We then looked for evidence of a public health impact for 

condoms in generalized epidemics. And to our surprise, we couldn’t 

find any such evidence. No generalized HIV epidemic has ever been 

rolled back by a prevention strategy based primarily on condoms. 

Instead, the few successes in turning around generalized HIV 

epidemics, like in Uganda, were achieved not through condoms, but 

by getting people to change their sexual behavior. 

UNAIDS did not publish the results of our review, but we did 

ourselves. And I would like to have this article summarizing our 

findings entered into the record. These were not just our hairbrained conclusions. A recent consensus statement in The Lancet

was endorsed by over 150 AIDS experts, including Nobel laureates, 

the President of Uganda, and officials of most international AIDS 

organizations. Dr. Gayle and I are both co-authors of this article. 

And I would also like to have this entered into the record. Both of 

these articles are in your packets. 

Mr. PAYNE. Without objection, both will be entered into the 

record. 

Dr. HEARST. This statement endorses the ABC approach to prevention: Abstinence, be faithful, and condoms. It goes further. It 

says that in generalized epidemics, the priority for adults should be 

B, limiting one’s number of partners. The priority for young people 

should be (A) not starting sexual activity too soon. Condoms should 

be the main emphasis only in settings of concentrated transmission, like commercial sex and known discordant couples. 

PEPFAR follows this ABC approach. Last year I was on a team 

reviewing PEPFAR’s prevention activities in three African countries for the Office of the Global AIDS Coordinator. We found a 

strong portfolio of prevention activities that included a mix of A, 

B, and C activities, although personally I would have liked to see 

even more of the B. 

This contrasted with other funders that often officially endorse 

ABC, but in practice continue to put their money into the same old 

strategies that have been so unsuccessful in Africa for the past 15-

plus years: Condoms, HIV testing, and treating other sexually 

transmitted infections. 

Now, one might well ask why they continue to do this, despite 

all the evidence. It is difficult to convey the tremendous inertia for 

doing the same old things. 

First, they are relatively easy to do. Second, many of the implementing organizations and individuals have backgrounds in family 

planning. They are very good at things like distributing condoms 

and providing clinical services, but they may not have a clue how 

to try to go about getting people to change their sexual behavior. 

Third, decisions are often made, and when we talk about letting 

people make decisions locally, remember this: By expatriates, 

Americans and Westernized locals who have been trained in rich 
35

countries, and who have internalized prevention models that are 

appropriate to concentrated, not generalized, epidemics. 

Finally, if you try to do a little bit of everything, expensive clinical services quickly eat up budgets, leaving little for the critical A 

and B of ABC. So for a lot of programs that say they are doing 

ABC, when you really look at it, 90 percent of their budget is going 

for other things. And yes, maybe they put up a billboard or two 

telling people to have fewer partners. 

Let me close with a warning about ABC-plus, or moving beyond 

ABC, and diverting AIDS prevention funding to whatever good 

cause people are promoting. Always ask, Where is the evidence? 

For example, I am all in favor of poverty alleviation. And CARE 

does great work, and I have worked for CARE, and I have donated 

money to CARE. But in most countries with generalized epidemics, 

the rich have higher HIV infection rates than the poor. Similarly 

for gender equity, many of the African countries with the best 

records in this regard, like Botswana for example, have the highest 

HIV infection rates. 

We have heard a lot this morning about integration, wraparounds, and removing funding earmarks to give local flexibility. 

And I understand the arguments for all of these things. But I am 

worried about the results. This would almost certainly result in 

less, not more, focus on changing sexual behavior, the only strategy 

that has worked for AIDS prevention in generalized epidemics, and 

therefore would have the potential to do more harm than good. 

Thank you very much. 

[The prepared statement of Dr. Hearst and material submitted 

for the record follow:]

PREPARED STATEMENT OF NORMAN HEARST, M.D., MPH, PROFESSOR OF FAMILY AND

COMMUNITY MEDICINE AND OF EPIDEMIOLOGY AND BIOSTATISTICS, UNIVERSITY OF

CALIFORNIA, SAN FRANCISCO (UCSF), SCHOOL OF MEDICINE

We’re here today to talk about making PEPFAR sustainable, and the key to sustainability must be prevention. We cannot treat our way out of this epidemic. Even 

now, five people are being infected with HIV in Africa for every one starting treatment. And treatment or not, these people will die of AIDS. 

For prevention, it’s fundamental to distinguish between ‘‘concentrated’’ and ‘‘generalized’’ HIV epidemics. These are different situations that require very different 

strategies. In most countries, HIV is mainly transmitted in high risk settings and 

groups, including men who have sex with men, injecting drug users, and commercial 

sex, so that’s where you need to do prevention. 

But in generalized epidemics, transmission is widespread in the heterosexual population, so you can’t focus only on high risk groups. Just a few countries in Eastern 

and Southern Africa have this pattern. But these countries, because of their very 

high infection rates, account for most of the world’s HIV infections. Most PEPFAR 

priority countries have generalized epidemics. 

Five years ago, I was commissioned by UNAIDS to conduct a technical review of 

how well condoms have worked for AIDS prevention in the developing world. My 

associates and I collected mountains of data, and here’s what we found. 

First, condoms are 85–90% effective for preventing HIV transmission when used 

consistently. We then looked at whether condom promotion has been successful as 

a public health strategy—something very different from individual effectiveness. 

Here we found good evidence for effectiveness in concentrated epidemics. For example, condoms made an important contribution to controlling HIV among gay men in 

places like San Francisco and epidemics driven by commercial sex in places like 

Thailand. 

We then looked for evidence of a public health impact for condoms in generalized 

epidemics. To our surprise, we couldn’t find any. No generalized HIV epidemic has 

ever been rolled back by a prevention strategy based primarily on condoms. Instead, 

the few successes in turning around generalized HIV epidemics, such as in Uganda, 
36

were achieved not through condoms but by getting people to change their sexual behavior. 

UNAIDS did not publish the results of our review, but we did ourselves. I would 

like to have the following article entered into the record: 

Hearst N, Chen S. Condoms for AIDS Prevention in the Developing World: Is It 

Working? Studies in Family Planning 2004;35:39–47. 

These are not just our conclusions. A recent consensus statement in The Lancet

was endorsed by 150 AIDS experts, including Nobel laureates, the president of 

Uganda, and officials of most international AIDS organizations. This statement endorses the ABC approach to AIDS prevention: Abstinence, Be faithful, and 

Condoms. It goes further. It says that in generalized epidemics, the priority for 

adults should be B (limiting one’s number of partners). The priority for young people 

should be A (not starting sexual activity too soon.) C (condoms) should be the main 

emphasis only in settings of concentrated transmission, like commercial sex. I also 

ask that this article be entered into the record: 

Halperin DT, Steiner MJ, Cassell MM, Green EC, Hearst N, Kirby D, Gayle HD, 

Cates W. The time has come for common ground on preventing sexual transmission 

of HIV. Lancet 2004; 364: 1913–1915. 

PEPFAR follows this ABC approach. Last year, I was on a team reviewing 

PEPFAR’s prevention activities in three African countries for the Office of the Global AIDS Coordinator. We found a strong portfolio of prevention activities that mixed 

A, B, and C (though, in my opinion, probably not enough B.) This contrasted with 

other funders that often officially endorse ABC but in practice continue to put their 

money into the same old strategies that have been so unsuccessful in Africa for the 

past 15 years: condoms, HIV testing, and treating other sexually transmitted infections. 

One might ask why they continue to do this despite all the evidence. It’s difficult 

to convey the tremendous inertia for doing the same old things. First, they’re relatively easy to do. Second, many of the implementing organizations and individuals 

have backgrounds in family planning. They’re good at distributing condoms and providing clinical services but may have no idea how to get people to change sexual 

behavior. Third, decisions are often made by expatriates and westernized locals 

trained in rich countries who have internalized prevention models from concentrated 

epidemics. Finally, if you try to do everything, expensive clinical services quickly eat 

up budgets, leaving little for the critical A and B of ABC. 

Let me close with a warning regarding talk about ‘‘ABC plus’’ or ‘‘moving beyond 

ABC’’ and diverting AIDS prevention funding to whatever other good cause people 

are promoting. Always ask, ‘‘Where is the evidence?’’ For example, I’m all in favor 

of poverty alleviation. But in most countries with generalized epidemics, the rich 

have higher HIV infection rates than the poor. Similarly, for gender equity, many 

of the African countries with the best records in this regard (like Botswana) have 

the highest rates of HIV infection. Anything that dilutes the focus of AIDS prevention in Africa from changing sexual behavior may do more harm than good.
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Mr. PAYNE. Thank you very much for all of your testimony. We 

have votes coming up, but I think we can begin our questioning, 

and then at an appropriate time we will leave, and hopefully you 

will be able to remain for the question period. 

I would like to begin with Dr. Hearst. You talked about the 

condoms and ineffectiveness in general. You mention that there are 

condom-only programs. And I wonder if you could talk about that. 

I was unaware that there would be programs where condoms 

would be distributed without any kind of educational material or 

people talking about the A and the B, also. So do you know of any 

programs that stress only condom distribution, without any other 

kinds of education, et cetera, that needs to go along with the whole 

concept? 

Dr. HEARST. Well, certainly that is not what we generally found 

for PEPFAR programs in the review in three African countries, 

where I was last year. 

But if we look historically at how condoms have been promoted, 

including often with U.S. Government funding, it has often been an 

approach called condom social marketing, where the goal is to provide condoms at below-market prices, make them readily available, 

and promote their uptake. And if you are not careful, and often 

what does happen is, success is measured in the number of 

condoms sold. 

And you promote a product where, you know, we are Americans; 

we know how to promote products. We can sell toothpaste; we can 

promote condoms. And these condom social marketing efforts will 

generally not be at all integrated into messages about changing 

sexual behavior. I could give specific examples; I am not sure how 

helpful that would be at this point. 

But I am not at all opposed to making condoms available. When 

I support ABC, I include the C in ABC. 

Mr. PAYNE. Would any of the other witnesses like to comment on 

the whole question? 

Dr. GAYLE. Yes, thank you. I would just like to add a few points. 

You know, I think the issue has really moved past whether A, 

B, and C are all critical elements for prevention. I think all of us 

would agree that all three components are critical. 

Our feeling is that we haven’t gone far enough. And particularly 

if you look at the issue of those who are increasingly vulnerable—

girls and women in the countries at greatest risk—our ABC strategies don’t really meet their needs. And abstinence, being faithful, 

and wearing condoms are oftentimes, in fact, usually not within the 

control of women. And women’s vulnerability actually derives from 

other issues, including their economic dependency, their social dependency, et cetera. And so I think we have to go beyond that. 

But I think spending a lot of time arguing whether it is A, B, 

or C really diverts from how we really have the best long-term, sustainable impact. 

Our concern is about being prescriptive at the country level, and 

not allowing countries to have the capacity and the ability to actually decide which program works best for them within their own 

cultural context, not allowing them to use the range of tools that 

will have sustainable impact on reducing HIV. 
50

Dr. MUKHERJEE. I would also like to add some pieces of evidence. 

I think there is actually more than ample evidence that poverty is 

a risk factor for HIV. 

Our group has done studies in Haiti, looking at the risk for 

women who contract sexually transmitted disease, their main risks 

being not having a proper roof over their head, and not having a 

radio, markers of their poverty, not of their promiscuity. These 

women with sexually transmitted disease had a very low number 

of sexual partners. 

The second, we also have evidence of economics and its relationship to having forced sex from within Haiti again. There are many 

other pieces of evidence that poverty is a risk factor, I know no evidence that being rich is a risk factor for HIV, other than very early 

in the epidemic, with air travel. And in fact, it was sexual tourism 

itself that brought HIV to Haiti in the beginning of the epidemic. 

And I don’t think at this point it is true that more rich people 

in poor countries have HIV than poor people. I work on the ground 

all the time as a clinician. The large majority of people living with 

HIV are very poor. 

Dr. DAULAIRE. I would just like to comment about the ABC debate. 

From the standpoint of organizations and health professionals 

working in the field, it is really a false dichotomy. And we have 

heard from Dr. Hearst, as well as from Dr. Gayle, that responsible 

programs really work across the spectrum, dealing with partner reduction, dealing with delayed onset of sexual activity, and dealing 

with provision of condoms and other reproductive health services to 

protect those who are at risk. 

And this is not new. I know that we have had a lot of discussions 

about this since the initial debate over the authorization of 

PEPFAR. But I would remind this committee that the signal success story that has been cited here, Uganda, where certainly the 

changes in sexual behavior were and have been an important contributor to the reduction in HIV, was not an invention of PEPFAR. 

In fact, Uganda had the greatest per capita contribution of United 

States Government AIDS support through the late eighties, 

through the 1990s, and into the beginning of this century, of any 

country in the world. So this was the consequence of a long time, 

with lots of people working there. And the A and B in Uganda were 

very much a part of the fabric that the United States Government 

was involved in promoting back before PEPFAR, as well. 

So I would just caution us against getting tied up in a debate 

that is perhaps not very real on the ground. 

Mr. PAYNE. Thank you very much. Could you put the screen on, 

and see how much time we actually have? Okay. 

Well, we have a few minutes left. And I will just yield to Mr. 

Smith, if he would like to begin questioning. 

Mr. SMITH OF NEW JERSEY. Thank you very much, Mr. Chairman. Let me begin with Dr. Hearst, with your focus on generalization of epidemics, or epidemics generalized as opposed to concentrated. 

I was struck by your comment that we then look for evidence of 

a public health impact for condoms in generalized epidemics. To 

our surprise, we couldn’t find any. No generalized HIV epidemic 
51

has ever been rolled back by a prevention strategy based primarily 

on condoms. Instead, the few successes in turning around the generalization of the epidemic, such as Uganda, were achieved not 

through condoms, but by getting people to change their sexual behavior. 

And you end with an important point, that anything that dilutes 

the focus of AIDS prevention in Africa from changing sexual behavior may do more harm than good. And yet you point out that 

UNAIDS didn’t publish the results. I am wondering why that was 

so and if you could elaborate again on this very provocative statement, which I think over the last 4 years is being proven true 

through evidence-based information that has been percolating from 

the field. 

Dr. HEARST. Well, I think the results that we found weren’t what 

UNAIDS expected. They weren’t what we expected going into it. I 

know there was a lot of internal debate about it at UNAIDS. I 

know a lot of individuals at UNAIDS who told me privately that 

they, you know, agreed with what we were saying, and appreciated 

what we were saying. I don’t think UNAIDS was prepared to make 

that sort of a statement at that time. 

There have been some changes in UNAIDS. Peter Piot supports 

ABC; says he supports ABC. Then the next moment he is saying 

that condoms are the only strategy that has been shown to work, 

which I have to kind of scratch my head when I hear. 

But I think that there has been some shift there. And hopefully, 

we will continue to see more of a shift in that regard. But of course, 

UNAIDS has to be very careful about what they do and say and 

put out, because, by their nature, they have to act as a consensusbased organization. 

Mr. SMITH OF NEW JERSEY. But again, publishing information. 

Had your findings proved the opposite, I am sure that finding 

would have been widely disseminated, would have been published. 

When evidence is gleaned that doesn’t support a pre-conceived notion, it gets put into a spike somewhere or put into a closet somewhere. This is very troubling and very disconcerting that a group 

would not want that information to go forward. 

We want it all on the table. And again, you found some information which many of us intuitively thought might be true, but you 

have found information and evidence that supports it. 

Dr. HEARST. Well, I agree with you. I will say they didn’t try to 

keep us from publishing it ourselves, as individuals. But they were 

not willing to put their stamp on it. 

Mr. SMITH OF NEW JERSEY. But again, the imprimatur of 

UNAIDS would have, I think, changed at least some of the debate. 

Because there has been a very strong debate, as you know. 

I am the one who authored the amendment dealing with the conscience clause, because we found, and we had ample evidence of it, 

that during the 1990s, large numbers of faith-based organizations 

that wanted to do abstinence and being faithful were precluded 

from U.S. funding. I used examples during the floor debate to back 

that up and I heard it anecdotally all the time, found clear evidence of it. From my point of view, changing sexual behavior certainly is one of the keys to stopping this. 
52

As I said in my opening statement, Mr. Chairman, I think it does 

smack of racism to suggest that some individuals are not able to 

change. I found, in my trips to Africa, that time and time again, 

the individuals, especially the young people in this Lancet piece, 

which Dr. Gayle has signed as well, makes it very clear that the 

first priority in targeting young people should be to encourage abstinence or delay of sexual onset. 

We found that apart from PEPFAR, Mr. Chairman, the rest of 

the international community was asleep at the switch, unwilling to 

buy into this idea. I think your testimony gave some reasoning behind that. A part of it is that they are focused on a concentrated 

epidemic, as opposed to a generalized one. Whatever other reasons 

might be out there, I think your statement was a very good explanation for that. 

So it seems to me—and you say so in your statement, that overall we are better off with earmarks than without them. Absent the 

earmark, it is my belief—and I would appreciate your view on 

this—we would have seen abstinence and being faithful again 

being put on a shelf somewhere. 

And I would just note parenthetically that Dr. Ilyoto, the head 

of the Uganda Parliamentary Committee that deals with 

HIV/AIDS, has said that we need more money for a debate. He is 

very concerned that the being faithful part is not getting ample 

funding, because that is where you can really change lives and also 

have a tremendous impact on whether or not people get sick. If you 

could, in the minute or so you have left. 

Dr. HEARST. Well, I would totally agree with that, on the B. And 

there tend to be passionate advocates for both the A and the C, and 

then unfortunately the B tends to get forgotten, when really reducing number of partners among the general adult population, in 

places with generalized epidemics, is probably the most important 

of the three. And it tends to get lost, sort of lost in the cross-fire, 

so to speak. So I would totally agree with that. 

In my opinion, the prevention earmarks in this first cycle of 

PEPFAR have done more good than harm. Any earmarks can be 

cumbersome. There can be times when local people feel that they 

tie their hands. They may be right at times. But I have just seen 

this too often, that if you don’t have an earmark, that we are going 

to spend at least this much of the budget on getting sexual behavior change, then it gets lost. People tend to see their AIDS program 

as a basket of services, and we have got to provide everything in 

the basket. And by the time you have tried to do that, the money 

is all spent on other things that are much more expensive. And the 

B, in practice, tends to get lip service, unless you specifically decide 

we are going to spend X amount on this. That is my concern. 

Mr. PAYNE. It looks like it is about time to recess. We will return 

in about 15 minutes, when these votes are over. Thank you. 

[Recess.] 

Mr. PAYNE. We will reconvene our hearing. And we will start a 

second round of questioning. We do expect a few of the members 

to come back, although many of them have lunch meetings to go 

to. 

Let me just ask Dr. Hearst. You closed your testimony and the 

discussion that we had with a warning about moving beyond the 
53

ABCs, and specifically cited concerns about focusing on issues such 

as gender inequality as a means of prevention. 

You said in your statement that African countries with the best 

records in this regard, like Botswana, which we already heard 

mentioned in the discussion, have the highest rates of HIV infection. I think that it was talked about that that was prior to, and 

as it has been moving on we see that there has definitely been a 

shift. And it may have been because of the mobility of people at 

that time. 

But what I find so interesting about the example you cited is 

that Physicians for Human Rights conducted an in-depth study, 

which was released earlier this year, which detailed the effects of 

gender inequality and discrimination on the spread of AIDS in Botswana and Swaziland. 

The authors found that in fact the HIV and AIDS epidemic in 

Botswana is undergirded by women’s lack of decision making on 

sexual matters, and prevalent gender discrimination. 

So I guess my question is, first of all, are you familiar at all 

about this report? I have a copy of it here. And have you, yourself, 

conducted an in-depth study on the status of women in Botswana, 

and its effect on the spread of HIV? And do you believe that because the status of women may be better, relatively speaking, in 

Botswana than in other African countries, that there is no gender 

inequality there; thus making social gender imbalances a non-consideration in the spread of the disease? 

Dr. HEARST. I was aware of that report. I have not read the report. And I can’t say that I have personally conducted research specifically on gender equity. 

I think gender equity is a very important issue and cause. I 

think, on the other hand, if you look at Africa, there certainly is 

no Muslim country in Africa that has high rates of HIV/AIDS, and 

it is not because they have better gender equity. And that the countries like Botswana and South Africa, some of the countries with 

the highest rates have—not to say that there couldn’t be more improvement; I am sure there can, everywhere—but if you tried to 

look at a correlation between the status of women in Africa, at 

least on a national basis, and HIV rates, you wouldn’t find it, or 

you would find it going perhaps in the other direction. 

By that, I am not trying to imply we shouldn’t be working on 

gender equity. I think there is a perception sometimes that by trying to change sexual behavior, we are talking about just telling 

disempowered young women, you know, you have to say no, and 

putting all the onus on them. And that is not how it should be at 

all. We should be working probably more with the older men than 

the younger women, the older men who are infecting these younger 

women, and making it no longer socially acceptable or okay for 

them to be pressing younger women to have sex with them. And 

taking some of this pressure off I would hope would be empowering 

for women, not repressive for women. 

So I am sure there are many situations where working with gender equity and HIV prevention can be synergistic. We just 

shouldn’t assume that the problem will go away if we get better 

gender equity, or that necessarily anything that is good for gender 
54

equity is what we ought to be doing for HIV prevention, or viceversa. 

Mr. PAYNE. Your plus, Dr. Gayle, you were saying ABC-plus. And 

once again, what were some of those pluses you were talking 

about? I think it kind of maybe contradicts some of what Dr. 

Hearst—I think we all agree that prevention is the way to go. I 

think that that goes without saying. 

I guess the question is: How do we go about prevention? How do 

you go about education? What are the ways, at the end of the day, 

to assist in prevention? And we are finding that there are a lot of 

different ways. I think everyone agrees that abstinence is very important; I don’t know anyone who doesn’t advocate abstinence. 

I think there are some who say, then, in case abstinence doesn’t 

work, now where do we go? And that was the point of some of the 

questions about a specific amount of funds earmarked for abstinence-only programs, where I think everyone talks about abstinence. You can’t talk about HIV and AIDS if you are not talking 

about trying to abstain. Well, if you are young, and I couldn’t agree 

more that the B is very important, that once you are of age, then 

what? You are not talking abstinence to a 35-year-old, generally 

speaking. 

So it is this question of the be faithful, limiting partners, et 

cetera. However, then, as Dr. Gayle said, it is difficult to do. And 

you even admit older men have a strong influence in communities; 

and therefore, how do you change their behavior? So it is far 

from—do you have any comments, or do any of the other witnesses? We have discussed it earlier, but I think that this is really, 

as we look at reauthorization, we have got to try to figure out what 

is going to be best for the amount—if we don’t get the $50 billion 

that has been requested. I think that is a good number. I mentioned $30 in Kenya on World AIDS Day in 2006. And 3 or 4 months later, the President also mentioned doubling it to $30 

billion. Maybe I should have said 50. [Laughter.] 

Yes, Dr. Gayle. 

Dr. GAYLE. Well, just to start it—I am sure that my other colleagues have additional points to make—on this issue of gender, if 

you look at the epidemic, particularly in Africa, it is fairly clear the 

numbers make the point. In the younger age group, for every one 

infection within a young man, there are three infections in the 

same-age girls. And so the ratio of female-to-male HIV infection 

makes it clear that this is an epidemic that is disproportionately 

impacting women, and particularly young women. Sixty percent of 

new HIV infections in Africa are occurring in women. And it should 

be no surprise. 

We know that for any sexually transmitted disease where heterosexual transmission is the main route of spread, it will have a 

greater impact on women. For biologic reasons, for social reasons, 

and for economic reasons. 

And so our comments reflect the fact that if that is the reality, 

and if behavior change is, in fact, the best route that we have at 

this point of reducing HIV infections, we have to look at what contributes to that behavior. 

And on the side of women, if we want to be able to change the 

underlying reasons that women are vulnerable to HIV, it is impor-
55

tant to look at what are the driving factors. They are often social 

and economic. 

If we want to look at the male side of the equation, which we 

must, as well, if we want to have an impact, then we do have to 

look at changing social norms, looking at what it is going to take 

to support men to think about gender relations differently, and 

really support very different behavior in men, while we give women 

the support to be able to reduce their own risk for HIV. 

So I think that those are the points that we tried to make. You 

know, when it gets back to this issue of whether or not an earmark 

is important to do that, again, I think that there is very little disagreement that all three components of the ABC equation are very 

important foundations. 

I think where we would differ is whether or not an earmark is 

essential for having that balance, and whether having an earmark 

that preferentially states that A and B are the components that 

have to be stressed is again where we have a difference, that we 

really do think that a comprehensive approach is important. And 

that including all three components will ultimately have the greatest impact. And tailoring that to the epidemiology, tailoring it to 

the population at need, continuing to make sure that we look at 

what makes the biggest difference for any given population. 

And then finally, I think, while it is true that the issues of what 

you do in a generalized versus concentrated epidemic are different 

in the strategies that are used, even within a concentrated epidemic, there are populations that are at greater risk than others. 

And we have to think about the fact that young women, particularly those who are living under economic hardship, are at greater 

risk; and that we do have to think about how you tailor a response 

that meets those who are at the highest risk, even within the context of a concentrated epidemic. 

Mr. PAYNE. Yes. 

Dr. MUKHERJEE. I would like to just mention one thing about the 

‘‘plus’’ issue. When I started working in HIV prevention in Uganda—I was part of the big push in the early nineties in Uganda, 

where the prevalence in the town that I worked in was 35 percent, 

which means of adults of child-bearing age, the prevalence was 

about 60 percent. Many of the adults were dying of HIV. 

And I was working on a program for children, 10 to 14. And it 

was before there was any issue of ABCDEF. There was no alphabet 

attached to the need, the urgent need that we had to prevent HIV 

infection in these young people before the onset of their sexual activity. We talked enormously about trying to delay the onset of sexual intercourse until marriage, until they had finished their education, et cetera. That was the focus of the program: To try to get 

them to understand HIV risk. 

And for these children in 92 schools throughout rural western 

Uganda, we had a 3-week course about how AIDS is transmitted, 

how it can be prevented, and reproductive health in general. 

When we asked these children what is your main risk factor for 

HIV, in school after school they said poverty. They did not say sex; 

they did not say rape. They said poverty. 

And I will tell you that for these women, children, and particularly girls, school is not free. And they were often sleeping with a 
56

man who would have a relationship with them, who would pay 

them for their school fees, as a calculated risk against being illiterate and not able to enter the job market. 

And when you ask children to make the choice of going to school 

or not going to school, and if someone will pay for that school, they 

will take that risk. And you can make the argument that it is actually not a bad risk, because one known person that they are sleeping with is much safer than being a servant and being raped, and 

being vulnerable for the rest of your life. 

So one of my feelings, and something that we do in Partners In 

Health as risk prevention, is thinking about getting rid of school 

fees; is helping children go to school. And is that an abstinence program? Well, in fact, it is. Because every study—again, these are 

studies—there is evidence that shows that the longer time girls are 

in school, the more likely they are to delay the onset of sexual 

intercourse. 

So the idea that we could sit and tell them about abstinence is 

one thing. But if you don’t have the actual choice, if you are robbed 

of your agency by poverty; and similarly, many of the women that 

we take care of in rural Haiti, in rural Rwanda, in rural Lesotho, 

they are bargaining for sex for food for their children. 

As a mother of a 14-month-old, who has been in 14 countries, by 

the way, I can say that I don’t know a single mother who, if faced 

with starving children, would not have sex with a man to feed her 

children and support her. 

So what is the plus? The plus is providing some means, some 

safety net as a way to do prevention. Whether it is school fees, 

whether it is income-generating programs, whether it is the provision of food to extremely needy families, these are AIDS prevention. 

And we can talk about abstinence, et cetera. These are rhetoric 

in terms of the decisions people are making that have to do with 

feeding their children, surviving, going to school. 

Mr. PAYNE. Thank you. Thank you very much. I see Dr. 

Boozman. 

Mr. BOOZMAN. I really don’t—I am just enjoying the comments, 

to be honest. I appreciate all of you all, that you spent, reading 

your bios, you have spent a good portion of your lives really in a 

very noteworthy endeavor, you know, trying to solve these tremendous problems. 

I agree with you, Doctor, that the school fees and that, poverty, 

you know, those are tremendous problems. It is just difficult, you 

know, as you do travel, and those of us on Foreign Affairs do have 

the opportunity to travel a lot, and get around and understand the 

extreme poverty in these countries. 

So I really don’t have any questions. Again, I just appreciate 

your-all’s work. I appreciate the fact that you are in the battle. And 

there are lots of differences of opinion as to how to get these things 

done. And yet we really do want to help you any way we can, and 

just appreciate your efforts. Thank you. 

Thank you, Mr. Chairman, Ranking Member, for having the 

hearing. 

Mr. PAYNE. Thank you very much. Mr. Scott? 
57

Mr. SCOTT. Thank you, Mr. Chairman. And I want to commend 

each of you, because each of your presentations has been very, very 

illuminating. They have been very, very informative. 

When I was in the Georgia Senate as a Georgia Senator, I authored the state law on sex education, mandating the teaching of 

sex education and AIDS prevention instruction in the Georgia 

schools. As you can imagine, it was a challenge in any school system. But in Georgia, that is a pretty, pretty tall order. 

And we had to deal with essentially what my good friend, Mr. 

Smith from New Jersey, raises what I think is the fundamental 

question, but also presents the fundamental opportunity and how 

to move further. 

One of my experiences in dealing with this issue was, and how 

do you deal with both of these—they are two separate entities. Sex 

education, you have got teenage pregnancy. But AIDS prevention 

begins to get another set of requirements to deal with. And you all 

have each expressed that. 

And how do we deal with it in the context of reauthorizing this 

program, and yet, to respond to Ms. Gayle’s concerns about we 

need to do more, and yours and everyone? How do we move forward with this, and yet address what I think are some fundamental concerns by members that were basically expressed by Mr. 

Smith? 

And I had the opportunity of having to wrestle with that, because there were many, with sex education—abstinence only, that 

is it. Nothing else. Nothing else, abstinence only. 

But then when I brought in the AIDS prevention instruction, everybody began to think and understand, ah. Because we are dealing with something that is happening after the cat is out of the 

bag. And it takes a different set of things here. 

So my question is—one of the reasons, before I get to my question—we solved that problem by, of course, emphasizing abstinence 

only in the sex education. But when it got down to the AIDS prevention, we came up with this analysis, which I think goes to what 

Dr. Gayle was talking about when she mentioned the local, I can’t 

remember exactly, but the local cultural differences and concerns. 

And that is where I want to ask my first question and get a response from. How do we move forward in what I think is needed 

to have a greater expansion on the treatment of AIDS, when you 

know you have got 90 percent of the children with AIDS in one 

strategic area? That is obviously a preventive kind of measure that 

we have to move forward for. And there is something local going 

on there. There is something different there that touched on what 

Dr. Gayle is saying. 

And I wondered, Dr. Gayle, if you could start by stressing, how 

do we reconcile the need to move beyond the abstinence only, to 

deal with the localization of the issue; the different cultural values? 

The point that Dr. Mukherjee was mentioning about the schools 

and the fees, that might not be the same elsewhere. 

And is there something specific that you could recommend to us, 

and what we can include in this bill going forward, that would address the need that you see as doing more, but yet could give room 

to work with the concerns of, say, my colleague, Mr. Smith? Because in order for us to move forward on this, we have to come up 
58

with something that we can work with the strain of thought that 

he is registering. 

Dr. GAYLE. Thank you. It is a very complex set of issues. Let me 

start, and I am sure some of my colleagues will also have comments. 

You know, I think this is an issue that we have wrestled with 

for a long time: How to make sure that we are looking at an inclusive process, and including the different aspects of this. And you 

know, again, I think we feel very strongly that there is probably 

less disagreement around what the right approaches are, and that 

it would be good to move past whether there is a single bullet that 

will have an impact on this epidemic. 

I think we now know, after 25 years, that in fact it has to be a 

comprehensive approach; that it has to include prevention and 

treatment and care and support. That we need to, if we are going 

to have a long-term sustainable impact, that we have to prioritize 

prevention, all the while knowing that access to treating is critical 

for those who are already infected with HIV. 

And if we look at what really drives people’s risk factors and people’s vulnerability for HIV, then we will be able to look at that in 

a way that takes into consideration localized needs. 

It is true that different countries have different factors that may 

contribute. But I think if we give countries the flexibility to plan, 

based on their epidemiology, based on their cultural traditions, incorporating those in their response, that in fact we will have the 

best ability to have programs that are tailored to the need. 

I just also want to touch on your issue of pediatric HIV infection. 

It is a critical issue. And even there, we recognize, as Dr. Daulaire 

said, that we can’t just focus on a very narrow approach that says, 

‘‘Get pills in mothers’ mouths,’’ without thinking about what are we 

going to do for the long-term impact of making children safe and 

improving child health. And we need to look at an integrated approach. 

Ultimately, what is going to have the greatest impact on reducing the number of children born with HIV is reducing the number 

of women who get infected with HIV to begin with, and giving 

women choices who are HIV-infected, to be able to reduce their 

chances of getting pregnant if they choose not to. So integrating 

with family planning services is critical for allowing women who 

are HIV-infected to choose not to become pregnant, if that is their 

choice. 

In addition, we have to continue to look at keeping women safe 

to begin with, so in fact fewer women contract HIV, and therefore 

are able to pass it on. So I think we have got to look at all of those 

factors, and continue to look at how do we allow countries the ability to make the choices that will serve their needs best. 

Mr. SCOTT. Dr. Gayle, if I may just follow with one question, Mr. 

Chairman. What we did in Georgia when we ran across that, because we had to work both the conservative side, the liberal side, 

the moderate side, to come up with a conclusion. We were all 

happy with abstinence, as far as the sex education and the courses, 

and how we taught it, with peer influence and that sort of thing. 

But when we got to the AIDS, we suggested, we came up with 

this compromise, that allow each local school system, in concert 
59

with their parents, the PTA unit at that school, to determine 

whether the C word, condom, could be dealt with only in the area 

of AIDS prevention. 

So my point is that, is there a recommendation that could be 

made, as we move forward with reauthorization of this, that we 

may want to come up with some kind of language in here that 

could give at least, maybe there is some formula. Maybe there is 

some level of attainment with the children. Maybe there is something there that could trigger and say if it is at this level or for 

this country, perhaps we allow that community of interest to determine for itself, given its values, as to whether we move with simply 

allowing the funds to flow with the condom use. 

Dr. GAYLE. Yes, I think options like that have a lot of potential. 

When I was with the Centers for Disease Control, we actually 

could only provide resources to states if they, for HIV prevention, 

if they had community planning groups that worked along with the 

state health departments. It was a CDC requirement that the communities were involved. Materials had to meet local standards, et 

cetera. So I think that there are ways in which one could incorporate an inclusion of communities, so that community standards 

and norms were actually what were used. 

And we have a lot of examples of how that is done in the United 

States, but also a lot of examples around the world, where the inclusion, the explicit inclusion of communities in planning the programs helps to make sure that programming is relevant to the 

community norms and cultural practices. 

Dr. MUKHERJEE. And in Uganda, we did just that in 1994 and 

1995. We asked the parents, and we worked with the PTA, just like 

you are saying in Georgia. 

And my experience working all over the world is that no matter 

where you are, parents don’t like to talk to their kids about sex. 

And they assume not talking is akin to the kids not doing it. And 

I think working with the parents to craft a message for children 

is completely reasonable wherever you are in the world. 

Dr. DAULAIRE. Let me just bring this back for a moment to the 

specifics of the PEPFAR reauthorization. 

What we are discussing here, I think, is really at the heart not 

of a debate between A and B and C; it is a debate between a medical approach, which says we will tell you what to do, and we will 

do it for you, and a developmental approach that says we will work 

with you to figure out the best solutions in your own context. 

And that is I think one of the fundamental concerns that implementing groups have with a hard earmark. Because it takes that 

flexibility in terms of working with local communities out of play. 

Now, I think all of us in development agree that culture is not 

destiny; and that, in fact, behavior change in sexual behavior is indeed feasible, and happens. But culture is also not just a speed 

bump. It is something that has to be understood; it is very contextual, as it was in Georgia, as you discussed. 

And what is clear here is that we need to, through this legislation, provide the enabling conditions for that dialogue to take place 

to engage communities, particularly those at highest risk, and to 

coordinate and to fold prevention care treatment into primary settings as much as possible, and to bring in these larger social con-
60

texts. Because it is really, it is not about changing sexual behavior, 

it is about changing social behavior, of which sex is one manifestation. 

Dr. HEARST. If I might just comment. When we talk about letting 

local people make the decision based on local situations, I mean, 

when you look at the successful Uganda example, as we have just 

heard, that is where it came from. It didn’t come from Western experts coming in and telling the Ugandans to do it this way. 

And unfortunately, what we Western experts have done far too 

often—and maybe that has gotten a little better in the last few 

years, I hope so—is we have gone in and told them condoms are 

the real solution. Condoms are the real AIDS prevention; all this 

other stuff is just nonsense. And that has been the model that has 

been followed in most African countries for the last 15 years. And 

that is certainly not because local Africans came up with condoms 

as, Oh, we have all sat down and thought about it, and decided 

condoms are the way to go. No, that is because the foreign experts 

came in and told them that. 

And in fact, unfortunately, in Uganda, after their great success, 

there has been a bit of backsliding. And it is partly because some 

foreign experts have come in and told them, ah, this zero-grazing 

thing, well, maybe that was fine; but, you know, get with modern 

times. You are doing a terrible job. You don’t have nearly as high 

condom-use rates as in successful places like Botswana and South 

Africa. And more and more of the resources went to condoms, and 

now we are starting to see HIV infection rates tick up a little bit 

in Uganda. 

So I am a little worried when—I am all in favor of coming up 

with local solutions, because they are more likely to work. But you 

have to be very careful how you do that. And the local solution 

tends to be what the foreign experts and the local elite that has 

been trained in the United States and Europe goes back and have 

internalized. 

So I think if we had real locally based solutions, we probably 

wouldn’t need to worry about earmarks. Because what most Africans understand is that this epidemic is sexually driven, and they 

would tell you themselves that sexual behavior is what has to 

change. 

Mr. SCOTT. So you are fine with that local; you see that as being 

very, very important. But what you are saying is that it needs to 

be, we need to have the program accentuated and grounded more 

with the A and the B, the abstinence and be faithful, and not allow 

the condoms or the local control to, or the local control to deemphasize the A and the B. 

I agree with you on that. I think it is strong; I think you are absolutely right about the abstinence. I think you are absolutely right 

about the behavioral. 

But I think that in terms of our policy here in getting something 

through or expanding this deal, I think we have to come up with 

language that can make sure those things are satisfied; that the 

concerns of, let us say my colleague from New Jersey, Mr. Smith, 

can be satisfied. Because they are my concerns, too. Because I 

agree, after going through this, if you can get them to stop it, don’t 
61

do it before time, and we can get that if we get it into elementary 

schools and we get it in there. 

But let us face it: This is a biological clock that is going to go 

off at at least 12 or 13. I mean, that is natural, it is going to go 

there. And once they engage in sex, then there has to be another 

approach, as your approach. If you have got to do it, do it with one 

person. And hopefully, get married. 

But when we are dealing with the primary problem, as what 

these ladies have pointed out, it is coming from these men. These 

old grown men that ought to know better. It is coming from these 

prostitutes. It is coming from those johns who do it. It is coming 

from all these other things. And when it is so persistent and rampant within that cultural there, that in one area 90 percent of the 

children of the world are AIDS here, clearly we have got to do this 

other third thing. And maybe the local control will do it. 

So anyway, that is my thought on that. And I just agree with all 

four of you. And I think you are doing a wonderful job. And again, 

Mr. Chairman, I say to you that I am anxious to join you in your 

next trip to Africa, because this is the number-one health issue in 

the world. And if we don’t move with it forthrightly and quickly, 

it is going to spread even greater. And we are the country to provide that leadership. It is our mandate to do that. It is our calling 

to do that. 

And thank you all for this excellent hearing. 

Mr. PAYNE. Thank you. Thank you very much for your interest 

and your passion. 

I see Mr. Chabot. 

Mr. CHABOT. Thank you, Mr. Chairman. I apologize for not being 

here for the testimony itself. I will certainly take the time to review the testimony of all the witnesses. I want to thank you for 

giving it. 

My only, I guess, comment would be that I had the opportunity 

to visit an AIDS facility some years ago, in Kampala, Uganda. This 

was a number of years ago. And about 3 weeks ago I was on a 

codel with a couple other members, and we went to Darfur, and 

then we also went to Ethiopia. And one of the things we did in 

Ethiopia was to go to an HIV/AIDS program put on by, I believe 

it was Save the Children, just outside of Addis Aboba. 

And it is really kind of heart-wrenching what you see there, to 

the extent that most of the kids were either HIV-positive and were 

orphans, or there was some connection that obviously put those 

particular children there at risk. 

And one of the main things that they stressed was that even 

though the drugs, the cocktail, is now available in many places, if 

the nutrition is not up to standards, then you are really wasting 

your energy and money, and the people aren’t going to survive anyway. So that has to be a key part of it, letting those children and 

families have adequate nutrition. 

And there were clearly bags there saying that this was from the 

people of the United States, and it was good to, certainly to see 

that. And I just wondered if—and you may have already commented on this, and if so, I apologize—but does anybody want to 

comment on that aspect that the nutrition—yes. Both of you. 
62

Dr. GAYLE. Yes, just briefly. We commented on this in our statement, and feel that the issue of food security is critical, both for 

prevention, as well as for people who are already infected with 

HIV. We know, and Dr. Mukherjee gave a very eloquent statement 

around how women, particularly poor women, often have to sell sex 

or exchange sex for food. Young girls, in order to get education and 

get their school fees paid for, often exchange sex in order to get 

adequate nutrition or education, et cetera. So we know that the 

issue of lack of stable source of food and food security does increase 

vulnerability to HIV. 

We also know that people who don’t have access to adequate nutrition and who are HIV-infected will sometimes use their money 

to buy food, as opposed to using it for their drug treatment, because the food is most essential. And that people who don’t have 

adequate nutrition aren’t going to be able to continue to comply 

with their anti-retroviral therapies. 

So yes, we think that food security is a critical issue. And I think 

it just continues to point to one of our core issues, that unless you 

address these social and economic underlying factors, both for prevention and treatment, we are not going to have the long-term, 

sustainable impact that we want to have on the epidemic. So we 

do strongly agree that we have to integrate food security with these 

other issues, as well. 

Dr. MUKHERJEE. Can I—I would like to add something specifically about children, which you asked, Mr. Scott, and also Mr. 

Chabot. 

You know, I think that the food security issue is central to this, 

as is health system strengthening, which was the topic of my testimony. But I have heard a couple times today you can’t treat your 

way out of this epidemic. And I am worried about that rhetoric. 

It is because of the advocacy around treatment that we now have 

the opportunity to do all of these other things, like prevention. 

Many of us, I think at least the two here that I know well, Nils 

and Helene, we have been working in HIV since the beginning of 

the epidemic. And prevention was not enough to garner the kind 

of resources that we now have. The activism around treatment. 

So the idea that you can’t treat your way out of the epidemic, let 

us not get too caught up in that. We have the opportunity, because 

of this money, to do much more effective prevention. 

One of the critical things in allowing people to use the messages 

of A, B, or C is knowing their status. But as my example showed 

you from our clinic in Haiti, people are not going to come and get 

tested if there is no availability of treatment, of primary 

healthcare. 

Similarly, if we are going to invest this money in treatment, we 

have to make sure that people have adequate nutrition to meet 

their needs. Because otherwise they will succumb to other infections, particularly tuberculosis. 

And then lastly, in terms of children, there is prevention and 

there is prevention. We have focused a lot of time in this hearing 

on the ABC issue. But there are two other parts of the prevention 

that are evidence-based, that are extremely important, that we 

have not even addressed. And one is the prevention of maternalto-child transmission of HIV, which Nils pointed out is a known 
63

therapy. It was the first important breakthrough in HIV in 1995. 

And 12 years later, we have less than 10 percent of pregnant 

women with HIV in Africa who know their status. Why? Because 

the health systems are broken. Because they have nowhere to come 

for prenatal care, for HIV testing. 

It is not because people don’t want the drugs. They are going to 

come if there is a health system that works. And that is why 90 

percent of children with HIV are in Africa. The epidemic is there, 

and women are not accessing prevention services because they are 

not wrapped into comprehensive prenatal care. Women should not 

be delivering babies in their homes. It is bad for their life. 

And so, and then the other evidence-based prevention that we 

haven’t talked about is the detection and treatment of other sexually transmitted diseases. Again, why is this not happening? It is 

not happening because health systems don’t work. Because people 

are not able to access the system that would allow them to treat 

diseases like syphilis, et cetera, that will decrease transmission of 

HIV. 

And it is in those settings that you can do prevention. We do prevention in churches, in schools, in communities, et cetera. But also 

the prevention is tied to people knowing their status, to being able 

to access the health system, and to be able to have a place that 

they can go to when they are sick. And that is, Mr. Scott, why the 

children are still being born with HIV infection, because their 

mothers don’t have access to primary healthcare. 

Dr. DAULAIRE. I completely agree with Dr. Mukherjee. This is not 

a debate, at least in our community, about treatment versus prevention. That bus has left. And it is very clear that when done 

right, and with high quality—and again, I would urge that in the 

enabling legislation, that the quality of treatment care be highlighted, not just the numbers—that that actually can be and should 

be an enhancement for all of the prevention programs. 

Clearly, the things that your committee needs to look at in terms 

of the legislation needs to be this issue of quality versus quantity. 

The issue of how to best increase prevention. And again, it is not 

a debate in our community any longer whether condoms versus A 

and B are the key things; they all have to be done in a systematic 

and coordinated way. 

Third, following the Institute of Medicine recommendation, 

healthcare worker training; and with that, strengthening the 

health systems, as Dr. Mukherjee has said. That needs to be built 

into the legislation as a part of what PEPFAR takes an active role 

in. 

And fifth, coordination across U.S. Government agencies, so that 

things such as food security and other issues that directly relate to 

the status of people living with HIV and at risk of HIV, are part 

of the fabric of this government’s response. 

Mr. PAYNE. Yes. Dr. Hearst. 

Dr. HEARST. I don’t have much to add. Just when I say we can’t 

treat our way out of the epidemic, I in no way intend that to mean 

we shouldn’t be doing treatment. 

What I mean by it is that we shouldn’t fool ourselves into thinking that treatment is in some way a substitute for prevention, or 

that it will necessarily result in prevention. There are ways that 
64

it can be synergistic with prevention, as we have heard; people 

knowing their status, and helping them not to transmit to others. 

But frankly, there are ways that it undercuts prevention. And 

my own research has shown this in gay men in places like Brazil, 

where treatment is rolled out, and people think, Oh, HIV is not so 

bad any more; it is a treatable disease. And they start backsliding 

on avoiding risky behavior. We have seen that in San Francisco. 

We have seen that in other places. 

I am not saying because of that, we shouldn’t provide treatment. 

We have to be extra careful that we don’t in our own minds start 

thinking that somehow treatment is a substitute for prevention. 

No, we need both. We need them both very much. And we need to 

find ways to make them synergistic, and not interfering with each 

other, because there is that potential. 

Mr. PAYNE. Mr. Smith? 

Mr. SMITH OF NEW JERSEY. Thank you, Mr. Chairman. Before 

asking two final questions, I would just make one observation. And 

I appreciate the testimonies of all of our very distinguished witnesses here today, and for your work. 

Last year, on May 25, I chaired—and you might recall, Mr. 

Chairman, because you were there—I chaired the African Global 

Human Rights International Ops Committee. We held a hearing on 

world hunger, and the crisis that we have. One of the major components of that hearing was the fact that, just like you or I, if we are 

on antibiotics and aren’t taking sufficient amounts of food, it 

doesn’t take long for that antibiotic to cause major-league stomach 

upset, in addition to perhaps not working as well as it could. Doubly so, triply so, how many times so for those that are on A or B. 

So that message was very clearly conveyed to us by our witnesses 

at that hearing. 

We also had a safe blood hearing. I remember one of the WHO 

witnesses saying that 44 percent of maternal mortality could be 

ended if we had access to a safe, durable supply of blood. The donors, as it would turn out, should not be paid because, if they are, 

you are more likely to get people who will not provide safe blood. 

We would need to establish as best as possible a system whereby 

volunteers would come forward and the blood would be screened. 

I myself have been in a number of African hospitals where you 

open up the refrigerator, and there are very few pints of blood sitting there, waiting to be transferred. 

So women, when they hemorrhage from a complication attributable to either the birthing of a child or some other maternal complication, just doesn’t have access to that safe blood. So it is something that we have tried, Chaka Fattah has pressed USAID on 

this, I have pressed them. Mr. Chairman, you have, as well, believing so passionately that access to safe blood could save so many 

lives. 

Even though it is a small amount that get AIDS in Africa from 

bad blood or tainted blood, safe blood is just not there. 

One other observation, as well, is that in seeking balance—and 

I remember when we were writing this legislation, because I, like 

others, was very much involved with the drafting of it. Obviously, 

Chairman Hyde was the prime sponsor and the prime leader on 

that issue. But we all kind of forget that we provided 15 percent 
65

of the funds for palliative care, 55 percent for treatment. Many of 

us have noted over the years that there was almost nothing going 

to help people treatment-wise, and this was a breath of fresh air 

for those suffering from the epidemic to be able to get these lifesaving ARVs. 

On the prevention side, 20 percent for prevention; 33 percent 

shall be expended for abstinence and being faithful. So it is a subset that we are talking about. And that was born out of a very 

real—and I appreciate Mr. Scott’s statements earlier—a very real 

observation that many of us made, inside and outside of the administration, those on both sides of the aisle, that abstinence and being 

faithful really got short shrift over and over again. 

I don’t mind having a condom inclusion, but it needs balance. 

And again, especially for young people, if you get a mixed message 

and you get it from people in authority, you might take the path 

of least resistance and just use a condom. 

And I take your point, Dr. Hearst, about the backsliding. I remember President Museveni being laughed at, frankly, by many in 

the international community. He stood firm, as did his wife, as did 

others in Uganda, and said the international community, we appreciate your help, but frankly, we want a locally based solution to 

this, and we want to save our countrymen and countrywomen by 

effectuating what turned out to be an ABC model, which has 

worked so very well. 

Let me also say when it comes to the children, not brought out 

in this hearing, but I will never forget in Ethiopia, when I visited 

an orphanage for HIV-infected children. There were about 500 kids 

there. As I walked around, I must have had more kids holding onto 

my arms on both sides. And if it wasn’t for the nuns’ love and compassion, and fighting to get ARVs and other helps, which was a 

daily battle for them, those kids might have been dead, certainly 

very sick. 

And yet they told me there are kids that they have to turn away 

for lack of capacity. So again, that percentage of balance of what 

we do with our HIV/AIDS money needs to be looked at very carefully, because those kids need help. And they also need help in the 

facilitation of adoptions when there are AIDS orphans. That means 

coming to the U.S. and going anywhere else where loving couples 

are waiting to adopt these very adoptable children, or making it 

work for them in a home with the grandmothers and others who 

very often are the greatest assistance in raising those children. 

Finally, let me just ask two questions. First, Dr. Gayle, you mentioned in your recommendations that we remove arbitrary restrictions and you include the anti-prostitution pledge, as you call it. 

Now, just a little bit of background. I am the one who sponsored 

that amendment to PEPFAR. It was born out of my work for at 

least 5 years prior to PEPFAR. It really actually began in the mid1990s; it came to fruition with a hearing that I held right there in 

1999, where we talked about the whole issue of sex trafficking, and 

the fact that, especially around the world, and here as well, it was 

exploding. The break-up of the Soviet Union, with the ease and 

availability of the Internet that moved women, and the fact that organized crime jumped in with both feet. All of a sudden we had a 

situation where women were being trafficked. 
66

Well, the amendment basically said that the organization has to 

have an anti-prostitution, anti-sex trafficking pledge. But as you 

know, and as I think everyone knows, in implementing the ABC 

final rule that guides how we spend this money, the money is 

available for people who are involved with brothels, women who 

are so-called sex workers. It is available for sexually active discordant couples; we already know that. 

But it is done in a way so that hopefully we don’t have a 

partnering with brothels and with the sex traffickers, to the detriment of those women. 

And your very next point, you say advancing an ABC-plus approach to address underlying vulnerabilities, you want to confront 

social norms that put women and girls at risk, as well as genderbased violence. It seems to me, I can’t think of a worse genderbased violence on the face of the earth than sex trafficking, where 

women are raped every single day, and these victims that I have 

had testify at probably a dozen hearings right in this room, where 

we have heard women tell their stories; I have gone all over the 

world, to shelters; those women need rescuing, not enabling. 

And again, that legislation, we thought we had balance. The 

model, in terms of money being disseminated by PEPFAR, can go 

to a woman in a brothel. But it doesn’t go to an organization that 

says we think this sex worker deal is okay. What kind of retirement benefits do they have? 

I watched a CNN piece recently. I was actually in Abuja when 

I watched it. I turned it on, and there it was, a half-hour piece. 

Very incisive piece. 

And in it, the reporter from CNN went down the streets in Bombay, and was talking to all of these young girls. Every one of them 

would say I am 24, I am 23. Every one of them was about 12 or 

13. And then they did a raid. The police let the women go—women; 

the young girls. 

And when they talked to the Sex Workers Union in India, they 

said every one of them is above majority age; there is not a minor 

among them. 

So I worry, and I worry deeply, if we don’t at least have some 

line in the sand and say the organizations need to realize that 

prostitution and sex trafficking is an exploitation of women; it is 

not an ennobling profession. 

The Court of Appeals for the U.S. District Court found in our 

favor that this language is permissible, and it actually comports 

with the goals of the PEPFAR legislation. So I am very distressed 

by that, frankly, because again, I have met so many women who 

have been trafficked. And frankly, women that I have met that 

have been in prostitution often have some dysfunction in their 

past. Usually it is an incest situation for many of them, and they 

are acting out their brokenness. And they need to be helped and 

loved, and brought out of that continuing exploitation. And it only 

helps the men who want to exploit these women. 

So I would ask you to reconsider that. And I ask that very, very 

strongly. Please reconsider, because I think that is a major mistake 

which will unwittingly enable gender-based violence against 

women. 
67

Secondly, and my other question—again, I would ask you to respond to that—Dr. Daulaire, you make a very good point about the 

child, the mother-to-child transmission issue about which we are 

not doing enough. You pointed out the bed nets and all the other 

things we need. And I couldn’t agree more. We have had hearings 

on that, as you know, Mr. Chairman. Both you have had them and 

I have had them, about why we need to incorporate these aspects. 

If you get malaria, obviously then you are on another train to sickness, and maybe even death. So I agree with that. 

But I was concerned when both you and Dr. Gayle say that we 

need to incorporate reproductive health services into that. And part 

of that is definition, and maybe you could tell me if I am wrong 

on this. 

But when I see organizations, like last October, we are talking 

about IPPF, International Planned Parenthood, the Packard WHO, 

Family Health International, and a host of other groups holding a 

conference in Ethiopia, linking reproductive health, family planning, and HIV/AIDS in Africa. That sounds reasonable on its face, 

until you try to understand what they mean by reproductive 

health. 

To many of us, it simply means abortion. Well, I open it up, and 

I read the report: It is abortion. They say it plainly in their report. 

That is what they are trying to pressure governments to do. 

When I met with President Mellis, and before that his Minister 

of Justice, about a year and a half ago, to promote what you and 

I talk about, the killings that occurred on the streets of Addis, I 

asked how and where they got the language to change their abortion law. They told me a U.S. NGO wrote it for them. 

So we are talking about local solutions, IPASS and IPPF, Equality Now and other groups are actively trying to impose, in my opinion, abortion on a traditional society that loves their unborn children, as well as their newborns. And then I look at some of the 

signers, and I see Dr. Cates with Family Health International. 

In 1976—and I just say this parenthetically—he wrote a piece, 

and I have a copy of it, abortion is a treatment for unwanted pregnancy, the number-two sexually transmitted disease. 

Pregnancy is not a disease. Unborn children are not parasitic 

life. And yet he treats it as if it is a disease. He is with Family 

Health International. 

Human rights are for all, from womb to tomb. They don’t start 

at birth; it is the beginning of life, much earlier than that, conception. Birth is an event in the life of a child after it has begun. This 

conference raises very serious, troubling red flags to people like 

myself. 

So how do you define reproductive health? Is it abortion? Is that 

what you mean? They say it clearly in this conference. Is that your 

opinion as well? 

Dr. GAYLE. I think that I will start with the first issue that you 

raised. And it is long and complicated, so let me just say, give kind 

of a simple answer. And we would be happy to provide further response to your question. 

I think our concern is, I think I would say we would share your 

concern about the issue of gender violence, what has happened in 
68

the case of particularly young girls who have been sold into commercial sex, et cetera. 

I think that the issue of the pledge, though, doesn’t address 

those. And I think what the concern of many organizations has 

been is that what happens, in terms of ability to work with organizations that work with commercial sex workers, has been hampered by this. And so it is really the application of the pledge 

versus whether or not organizations—and I think most of us would 

say we don’t feel that commercial sex is the best option for women’s 

economic viability. But we also do accept the reality for women, 

particularly poor women. Sometimes that is the only option available to them, and we want to be able to work with commercial sex 

workers to reduce their risk of HIV infection, all the while recognizing that the risks that women put themselves in in the sex 

trade are not positive. 

Mr. SMITH OF NEW JERSEY. Would the gentlelady yield, just very 

briefly? I think that is where we differ. I don’t think that it is an 

option, no matter how desperate. 

I mean, I wrote two micro-credit laws. I believe desperately and 

passionately in the need for economic empowerment, which is why 

I did the two micro-credit laws. The Trafficking Victims Protection 

Act was my bill. It was a totally bipartisan bill, but I took the lead 

on it. 

It is not ennobling. It hurts women. It is just like allowing these 

men, as Mr. Scott and others talked about, who are abusing these 

young girls. We can’t——

Dr. GAYLE. No, by no means am I saying that this is a good option. The reality is——

Mr. SMITH OF NEW JERSEY. It should not be an option. 

Dr. GAYLE. The reality for many women, is that it is the only option they have to put food on their children’s plates. And commercial sex is an option that people take, and they are therefore at 

great risk for HIV. And we want to be able to continue to reduce 

their risk of HIV, understanding that the long-term consequences 

of commercial sex have their own set of risks. So we recognize that. 

Mr. SMITH OF NEW JERSEY. I understand that. But——

Dr. GAYLE. We also recognize that operationalizing that pledge 

has many times driven a wedge between our ability to work with 

the very group at greatest risk. So that is our concern. By no 

means—and we have gone on record, as have most NGOs gone on 

record, saying that we do not support prostitution. And we are 

comfortable making that statement. 

Mr. SMITH OF NEW JERSEY. But the very groups that brought 

suit refused to sign it. They are affiliated with and have connections or links with some of the groups, like Adam and Eve, which 

is involved with a lot of sexual paraphernalia. 

But the emergency plan makes it clear, makes it clear that they 

can provide sex workers, as they call them——

Dr. GAYLE. Right. All I can say is that we are on record as opposing prostitution. We believe that that is the correct position. 

On the other hand, we don’t want language that in fact drives 

a wedge——

Mr. SMITH OF NEW JERSEY. It is also sex trafficking, as well. 
69

Dr. GAYLE [continuing]. Drives a wedge. And we, of course, would 

agree with that, as well. But we don’t want language that in fact 

drives a wedge between us and the ability to in fact reduce women’s risk of contracting a deadly disease. I think that is where we 

feel that operationalizing that pledge has not been beneficial to 

being able to reduce women’s risk of contracting HIV. 

On the other issue, for us, when we talk about reproductive 

health, what we are talking about is linking women who are HIVinfected with the ability to have access to family planning. And in 

that case we are talking about whether it is pills, whether it is diaphragms, whatever is the best locally available option for women 

who are HIV-infected, who do not want to continue getting pregnant, which, you know, the data all show that women who have 

one HIV-infected child are very likely to have another one. So we 

want those women to have the option to avoid pregnancy if they 

are HIV-infected. So linking them with family planning services is 

what we were addressing in our paper. 

Mr. SMITH OF NEW JERSEY. But do you define reproductive 

health as abortion? 

Dr. GAYLE. In our paper, what we were talking about was linking 

women with whatever range of family planning services are legal 

and safe, within their country context. We are not advocating for 

any particular method. We recommend and support a country’s decision to put their own standards on what reproductive health services are available in their country context. 

So our recommendation is, in fact, to link people with their country’s family planning services. We don’t prescribe what those services are. Countries have the right to choose what their range of reproductive health services are. Ours is linking women with those 

services; it is not supporting any particular strategy. 

Mr. SMITH OF NEW JERSEY. But you know as well as I, and I appreciate the indulgence of the chairman, that many of these conferences are put on by foreign NGOs, United States based and European based. And they bring an agenda. And that agenda, time 

and time and time again, and I read much of it, is abortion. 

So it is not like it is a locally indigenous clamor for abortion. It 

is very much manipulated by foreign NGOs. And this conference is 

just one example of many——

Dr. GAYLE. I can’t speak to the conference. Our point was that 

women who are HIV-infected should have the option to have access 

to family planning, and be able to make decisions about whether 

or not they want to get pregnant, knowing their HIV status. 

Mr. SMITH OF NEW JERSEY. I understand. 

Dr. GAYLE. You know, I would just again say that we do believe 

that countries and professionals within those countries have the 

ability to make safe decisions, make sound decisions. And I think 

we are past the point where a foreigner can parachute in and dictate to countries. I don’t believe that we so overwhelm people’s best 

thinking because we have foreigners involved. I think we are past 

that. I think we have, throughout the world, very bright professionals in the countries where we are working. They can make up 

their own mind. They can choose the methods that they think are 

best for their own cultural circumstances, for their own country’s 

circumstance. 
70

And you know, I think the thinking that we are so overwhelming 

people’s decisions, I think is just not true any more. I think that 

you will find bright, well-educated professionals in these countries 

that will go toe-to-toe with any of us on being able to decide what 

is best for their own populations. 

Mr. SMITH OF NEW JERSEY. Before going to—do you describe reproductive health as abortion? Is it included in the definition? 

Dr. GAYLE. In our statement, we are not advocating any particular methods. What we are advocating is that women who are 

HIV-infected have access to family planning services, the family 

planning services that are available in their countries. It is not a 

statement about one method or another, nor is it a statement about 

what is available in any given country context. It is a statement 

that women should have access to family planning. HIV-infected 

women should have the option of practicing family planning and 

avoiding pregnancy if, in fact, that is their choice. 

Dr. DAULAIRE. Congressman Smith, I know that we have had 

this conversation for probably over a dozen years back at various 

points. And I know there is a tendency, particularly in a political 

environment, to ascribe certain meanings to certain code words. 

And I know that reproductive health services have come to be a 

flashpoint on that. 

In my testimony, as submitted, I think I was clear, but in case 

I was not, I will restate what I thought was clear. Which is that 

an access point for women to get HIV testing, an excellent access 

point is in family planning clinics and places where they can get 

reproductive health services. 

Did I mean places where they should go for abortions? No. But 

is the reality that in some countries, that abortion is included 

among those services? Yes, it is true. Relatively few countries. 

But I was talking about family planning, I was talking about 

treatment, diagnosis and treatment of sexually transmitted infections, I was talking about services that deal with female genital 

cutting and mutilation and so forth. 

Do I believe that abortion is an appropriate treatment for HIV? 

No. It is not something that I or our members would recommend. 

Now, as you recognized, the Global Health Council is a big-tent 

membership organization. We have members, individuals, professionals, as well as organizations, who are pro-life; we have members who are pro-choice. And we have actually been able to engage 

a constructive dialogue on common issues, where we can all work 

together. So the Global Health Council doesn’t take a position one 

way or another on this very heated subject, but believe that this 

is a matter for national decision making, not something that either 

external NGOs or external governments ought to be imposing on 

countries. 

There is a rich debate and dialogue going on in many places, and 

we feel that countries should decide. 

Mr. PAYNE. Mr. Fortenberry? 

Mr. FORTENBERRY. Thank you all again for coming, and for your 

testimony today. 

There is a lot here. May I ask a simple question? We have Uganda, we have Botswana. Lowest incidence of transmission, highest 
71

incidence of transmission. What are the distinctions in the countries? 

Dr. MUKHERJEE. It is not a simple question, and you know that. 

And I don’t think actually it is a question of highest incidence, lowest incidence. Because in fact, Uganda was the epicenter of the epidemic in the early nineties. 

And many things that Uganda did allowed that rate to come 

down. And I think Mr. Smith mentioned President Museveni. But 

when I was working in Uganda, President Museveni appeared on 

many occasions with a condom on the end of a pen, giving lectures, 

trying to give the population all of the avenues they could have to 

prevent HIV. 

And I think the thing that should be really noted, and I think 

Dr. Daulaire pointed this out, is an enormous, enormous amount 

of resources went into Uganda for prevention at the time. Because 

there was no, they were the only game in town. There wasn’t an 

HIV epidemic raging throughout the continent, as there is now; 

and Southern Africa hadn’t even yet been hit by the epidemic. 

What is special about Botswana? I don’t think anyone knows. 

There are academics at my institution, at Harvard, that think it is 

the type of virus. I disagree. There are people that think it is sexual practices, cultural practices; I disagree. 

My personal opinion, what I tell my students at Harvard Medical 

School is if you want to understand the AIDS epidemic in Southern 

Africa, particularly in South Africa, but this applies to Botswana, 

Namibia, Lesotho, Swaziland, read the book Cry, the Beloved Country, which was written in 1948, by Alan Paton long before there 

was an HIV epidemic. And what it describes was the way Black 

labor was set up under apartheid; the way the mining economy 

robs Black men of the ability to live with their families. 

And in fact, it was apartheid legislation set out in 1948 that said 

that Black men could not have settled labor. They could not bring 

their wives and their children to live in the mines with them. 

What does that say? I think there is a lot of—I mean, I am a 

woman, obviously, but I think there is a lot of male blaming that 

goes on in the HIV epidemic. If men had the ability to have local 

choice of economic viability to support their families, I think they 

would take that. 

I worked in a country, Lesotho, where at any given point more 

than 80 percent of the people attending clinics are women. The 

men work in the mines of South Africa. There are no economic opportunities for them in Lesotho. 

So I think we have to think about this as a social context. You 

know, there are mining companies that are making a lot of money 

off of Black labor. And men are not allowed to bring their families. 

There are no settlements. And some of these companies even bus 

in prostitutes to make these men happy. 

Whose fault is that? If you are making less than $1 a day, and 

you are living 10 hours from your family, and the bus ride is going 

to cost 6 months of your wages, how often are you going to be able 

to see your wife for a conjugal visit? And I think this is the reality 

in Southern Africa. The epidemic has been fueled by a mining economy, by extraction of Black labor on the backs of poor people who 

really have no economic option. 
72

And I really think that Uganda has been progressive in dealing 

with their AIDS epidemic in many, many ways. But they had a lot 

of help, and they had a very broad-based strategy that included abstinence, fidelity, condoms; but also included the international community’s focus on that one country at that time. 

Dr. GAYLE. I would just add also that if you look at the recent 

trends in Botswana, the rates are starting to come down. So I 

think, in the same period of time that Uganda was able to see a 

response, Botswana is now also seeing that same sort of response, 

using a comprehensive approach. But the epidemic in Botswana occurred more recently than the one in Uganda. 

So I think if you look at the two, in fact, there are similarities, 

and the rates of infection in Botswana are starting to come down. 

Dr. HEARST. Well, just to say that, although I agree with some 

of the things said, there is a little bit of people wanting to look at 

everything but the obvious cause. And Botswana is the poster child 

of an African country that is, by African standards, not poor; that 

has spent far more per capita on prevention than was ever spent 

in Uganda in the early days. In fact, the whole zero-grazing campaign was done on a shoestring because there weren’t many foreign 

donors there at the time, which is probably why they did it right, 

because there weren’t all those foreign experts. 

And Botswana has done everything the West has told them to do. 

And it didn’t work. And yes, their rates have now plateaued. You 

know, they couldn’t go up to 100 percent. They have plateaued at 

absolutely horrendously high rates. 

Rates did go down in Uganda dramatically, and we are starting 

to see, it is not just Uganda, we are starting to see rates go down 

in parts of Kenya, parts of Zimbabwe. And every one of those 

places where infection rates are going down, we are seeing changes 

in sexual behavior, by our own DHS surveys, which our Government supports, as what has to happen first. 

So people seem sometimes just not to want to acknowledge what 

is right in front of them. I don’t know, but I think it is pretty clear. 

You can just go to those countries. You know, you go to Botswana, 

and you see all the obituaries in the newspaper, but they never say 

the cause of death of all these young people. Whereas in Uganda, 

you get in a taxi, and the taxi driver, when they find out you are 

there working on AIDS, has a million very cogent questions for 

you. 

It is a local response that has dealt with reality in Uganda that 

has worked. 

Mr. FORTENBERRY. Thank you. And let me say, Dr. Gayle, in 

your testimony earlier, you said a phrase that I think was very 

powerful, that I think should cause scandal to us all: Survival sex. 

And I pulled that out of all that could be said. Because look, yes, 

socio-economic contexts are important in this overall question. And 

the scandal that someone would have to turn, in order to survive, 

to the most degrading types of activity to feed their child or to feed 

themselves again should prick the conscience of the entire world. 

And so I appreciate the enlarging, or the augmenting of the discussion to the larger social context, I do. 

I do think, though, that, as Dr. Hearst points out, we need to be 

clearly understanding of what the evidence is before us, when this 
73

harder thing to do is actually engaged, to talk about self-dignity, 

self-worth, preservation of this most precious gift of one’s sexuality 

that can be used for great good or great harm has got to be an integral component, a decided emphasis, as we talked about earlier. Or 

else we are not living up to the standard I think the American people would want us to set with their tax dollars, in our approach in 

trying to be compassionate and saving lives of the world’s most 

needy people. 

So anyway, I will leave it at that. Thank you again for this discussion. 

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

Mr. SCOTT. Thank you, Mr. Chairman. I have a couple of points, 

but I must react to Dr. Mukherjee’s comments, because I think you 

nailed where we need to go. I mean, there needs to be a greater 

leeway, I think, as we move forward in this reauthorization, to emphasize the distinct community differences. The historical context 

that you gave of the impact on the African male certainly has to 

be a part of this equation. And I just wanted to let you know you 

were right on target with that, and I think that gives ample reason 

of where we have got to go, really. 

And I think we can get there without the abortion concerns that 

are there. And it is something that if we move forward in doing 

some of the things we want to do, we have got to find a way to 

give those assurances to the American people that——

Mr. PAYNE. That is another hearing. 

Mr. SCOTT [continuing]. Their concerns about taxpayers’ dollars 

using for that is not, you know, one having worked with that issue, 

and have made grounds on it, I think we can do that. 

But let me ask this of each of you first, very quickly. Do you feel 

that we could do a better job, and would you recommend that the 

funding for this program be exclusive for HIV/AIDS? I mean, we 

are here talking about the reauthorization of this act, and it is a 

multiple-disease act, bringing in tuberculosis and malaria. But yet, 

neither of those was even mentioned today, which gives some indication as to the seriousness and the overwhelming of HIV/AIDS. 

So there is a question out there that I would like to have your 

response to. Do you think, would you agree? Should we change 

this? Should we make it just deal exclusively with HIV/AIDS? And 

then, if that be the case, how would we make up for the deemphasis, or where would we go to deal with malaria and TB? 

Dr. GAYLE. Well, I think that clearly HIV is an unprecedented 

public health challenge, and we need resources that are focused on 

HIV and AIDS. We also need resources that allow us to effectively 

deal with malaria and tuberculosis. 

And as Dr. Daulaire said, I think we really need to make sure 

that we look at global health in a more comprehensive way. Because, while we have increased our funding on HIV, we have not 

continued to keep pace with other core issues, like child health and 

maternal health. 

So I think we have the ability to really look at a more comprehensive global health approach. 

For HIV, however, I think there is a need to have a real focus. 

And the things that we are talking about, we are not saying that 

we should solve all the problems of poverty through an HIV spend-
74

ing plan; but really, if we are going to have an impact on HIV, we 

have to look at these other factors that so influence prevention and 

treatment for HIV, and that we have to look at it in a comprehensive way. 

The focus is still HIV, but it is looking at what is going to be 

most effective. And what is going to be the best way to have a sustainable response. So we think it needs to be integrated with the 

focus still being on what is our impact on HIV and AIDS, on preventing HIV, on getting people treated and providing care and support for those with HIV and children affected by the epidemic. 

Mr. SCOTT. So you would go on the side of saying that it should 

be exclusively devoted to the HIV and AIDS. 

Dr. GAYLE. I think that the focus should be on HIV. That doesn’t 

mean that we should be neglecting the other diseases that are part 

of the overall package. 

Dr. MUKHERJEE. Yes, I would say that it is important to keep the 

focus on HIV. But I would strongly add tuberculosis. 

Tuberculosis and HIV are essentially one disease in most of the 

developing world. Fifty percent of all mortality with HIV is related 

to tuberculosis. And many children who are born to HIV-positive 

parents, even if the child themselves is not infected with HIV, will 

succumb to tuberculosis, because the parents have tuberculosis. 

And it is very difficult to detect tuberculosis in children. 

I think there has been such a focus on numbers of patients in 

HIV treatment, rather than the comprehensive HIV program. And 

to me, we can still look at health systems strengthening. If we are 

going to do enough HIV tests, if we are going to find pregnant 

women with HIV and provide them with therapy, we have to have 

that health system strengthened. 

You know, I think that tuberculosis programs and integrating 

testing for HIV within tuberculosis programs, and vice-versa; that 

everyone with HIV should be screened for tuberculosis. Again, 

these diseases go absolutely hand-in-hand, and I think we should 

have more leeway for that. 

Dr. DAULAIRE. Mr. Scott, as I said in my testimony, I do not 

think that we should limit ourselves to a narrow view of just HIV, 

and I would not recommend that the new PEPFAR authorization 

be exclusively and narrowly restricted to HIV. 

I think it is very appropriate to have it be the predominant focus. 

But, as I have laid out, and as we have heard elsewhere, there are 

so many interactive issues. And because the level of resources for 

PEPFAR is such an order of magnitude greater than it is from U.S. 

sources for other global health activities, it is going to be essential 

at times to be able to support ancillary kinds of programs that are 

directly pertinent to improving the health of people with HIV in 

their communities. 

Dr. HEARST. Well, I guess you are asking a panel of HIV/AIDS 

experts, so maybe we are biased. And maybe because I spent so 

many years working with HIV/AIDS, I think it is terribly important, so I am reluctant to have the funding for it be used for other 

things, as well. 

But on the other hand, malaria and TB are very important, as 

well. And I suppose if they received anywhere near the funding 

that they need and deserve, no one would even consider why one 
75

would have to tie them in with HIV funding. So it is sort of a sad 

commentary that that seems to be the only way they have gotten 

any attention. 

Mr. SCOTT. I would like to just ask again, as we look at the reauthorization of this, it would be good for us to know from each of 

you what recommendations, what changes; what would you like to 

see added, if each could add one thing that you would like to see 

added as we move forward to reauthorization, what would that be 

that is not there now? 

Dr. DAULAIRE. I went through a list earlier, and I will repeat it, 

because we have had a lot of discussions with the Global AIDS 

Roundtable and the HIV Implementing Group to discuss this. 

Prevention should be increased. There should be a greater focus 

on——

Mr. SCOTT. When you say prevention must be increased, are 

you——

Dr. DAULAIRE. A higher level of resources going to prevention. 

Mr. SCOTT. Okay. 

Dr. DAULAIRE. Secondly, the focus on quantity of treatment, 

number of people under treatment, needs to be balanced out also 

by markers of the quality of treatment. 

Third, healthcare worker training needs to be a part of PEPFAR, 

because it is turning out to be the critical constraint; and up until 

this point, to a considerable extent, it has sort of been somebody 

else’s problem. 

Fourth, as Dr. Mukherjee has made a clear statement about 

health systems strengthening, the broad systems that serve not 

only HIV programming, but other health programs, that you can 

only do in a systematic way need to be a part. And they should 

probably be an entirely new section of the PEPFAR bill. 

And fifth, there should be stronger language requiring and enabling coordination across U.S. Government agencies. 

Mr. SCOTT. Okay, fine. Thank you. Ms. Gayle. 

Dr. GAYLE. I would agree with those, and again, the increased 

focus on prevention. The way the spending ratios are now structured, it does tilt the spending in favor of treatment, and we think 

that prevention should be prioritized in the next round. 

Mr. SCOTT. Could you tell us what that ratio is now? That would 

be helpful. And what you would like to see the ratio be? 

Dr. GAYLE. I believe it is 50 percent on treatment. I don’t have 

an exact ratio; I think in any disease, the tendency to focus more 

on treatment over the long run is there. It is a lot more visible to 

treat people who are already infected. I think focusing on prevention, in the long run, is going to have the most sustainable impact. 

So I think we would just like to look at those ratios, and look 

at how we could increase and have a higher priority for prevention. 

Again, we’re not getting into a debate of prevention or treatment, 

because it needs to be a comprehensive response. 

Mr. SCOTT. May I just ask you one thing on the prevention? 

When you say an increase on prevention, and I think I picked up 

from, I think, both of you, Dr. Gayle, and Dr. Mukherjee, that the 

area where prevention can be increased the quickest, and where we 

need to concentrate and impact, is in the area of mother-to-child 
76

transmission. Could you tell us how we could improve that area of 

prevention? 

Dr. GAYLE. I guess I would disagree that PMTCT is where we 

need to put our highest focus, on reducing mother-to-child transmission. PMTCT is a smaller proportion of all new infections. 

I think the point that Dr. Mukherjee was making was that 

PMTCT is something that we have an incredibly effective intervention for, and still only about 10 percent of women who could benefit 

from that intervention have access. And so it is something that we 

could scale up very rapidly, and have a huge impact on reducing 

the number of children who are born with HIV. 

That said, it is a small part of the overall epidemic. And the real 

driver is women who get infected to begin with. And I would argue 

that the greater focus ought to be on reducing the spread of HIV 

in women, who are now increasingly disproportionately impacted 

with HIV. We could decrease the number of new infections dramatically, and we would also decrease the number of children who 

are born with HIV by really focusing on women. 

So our second point is, in fact, having a greater focus on women, 

and making sure that the strategies that are included allow us to 

look at the drivers, the underlying causes, the issues that put 

women at risk and increase their vulnerability to begin with; and 

therefore, look at it from much more of a development standpoint 

that includes the social and economic factors that put women at 

risk to begin with. 

So those would be our main points. This greater integration of 

social and economic factors, looking at the issues that increase 

women’s vulnerability to poverty, and increasing the focus on prevention. 

Mr. SCOTT. Okay, thank you. 

Dr. MUKHERJEE. I have to say that the idea of increasing money 

spent on prevention personally makes me nervous, because I think 

it is almost impossible to measure the efficacy of prevention, because you really have to look at the landscape over time: 5 years, 

10 years, 20 years. And also because it is very hard to measure 

new infection. 

I think that prevention is very, very important, but I don’t mythologize prevention. I think we have to have communities that are 

engaged in prevention, and that can be done through anything that 

brings people together, whether it is a church, a school, you know, 

a health clinic, et cetera. 

And so I personally think that we have to focus on outcomes of 

integration of these services. I think there has been a lot of focus 

on targets of people on HIV medicines, and I think that is okay. 

But we still should be looking at the number of people who engage 

in primary healthcare, who are getting HIV tested. And those numbers should be, we should have, you know, for every hundred patients that are tested, we should 5 percent that are positive, or 25 

percent if the case is Lesotho versus Haiti. We should be using it 

as a screening test, so that when people are in their prevention 

programs, they know their status, and that those messages can be 

helpful for them to protect themselves and others. 

And I would like to see ways to integrate, so say that this money 

is actually improving health systems. This isn’t being dropped in 
77

for an HIV intervention; that it is actually allowing people to get 

tested, allowing pregnant women to get tested, allowing children to 

be tested. And also allowing us to detect tuberculosis and treat tuberculosis so that people, you know, who have that disease won’t 

die, and also spread it to others. 

So I think that if we can look at ways of having this money be 

integrated in improving health systems, and integrated into ways 

that prevention can be more successful. I think putting, you know, 

half money treatment, half money prevention, we should look at 

what are the desired outcomes. 

The desired outcomes is to lower the overall death rate from 

HIV, to lower the overall prevalence globally of HIV. All of those 

things are going to take time. But are there process indicators that 

we can look at that say this money is actually providing people 

services they need to protect themselves against HIV? Or, if they 

are infected, protect themselves against death from HIV. 

Mr. PAYNE. Okay. Dr. Hearst? 

Dr. HEARST. Yes, thank you. I would agree with a lot of the recommendations so far, and just want to follow on a couple of the 

things that have come up. 

Fortunately, we are talking about a growing pie, as I understand 

that the question is how much it is going to grow. So I would also 

think we should put more of an emphasis on prevention. But fortunately, that ought to be possible, while still letting treatment efforts grow, as well, even though perhaps a little less proportionately. 

I think the point was made of it being difficult to measure the 

impact of prevention measures. And you know, part of the problem 

frankly with PEPFAR is that it has been difficult to measure because we haven’t tried to measure it. In fact, PEPFAR, the way it 

is set up, has been interpreted as prohibiting measuring it. There 

is no money, not only no money for academic research; there is no 

money for what might be called operations research, or even for 

what you might call decent program evaluation. And we need to 

have better information and know what is working for prevention. 

On treatment, we know what works. You can count the number 

of people on treatment. For example, we may know that this program is going out to a certain number of primary school children, 

but is it really having an impact on when they start becoming sexually active? We know X number of condoms were shipped, but how 

many people are really using condoms consistently, and are they 

the people who are the ones who are at highest risk? 

These things are measurable. It is not that hard to do, but it 

won’t be measured if we don’t try to measure it. Are we affecting 

the B if we are trying to get people to reduce their number of partners? What are trends in number of partners? You can set things 

up so that you, for example, roll out new programs one district at 

a time, and you can measure their impact. And we haven’t been 

doing a good job of that in PEPFAR at all. 

Mr. SCOTT. Dr. Hearst, if I may ask you this question. 

Mr. PAYNE. Mr. Scott, we have to be out of here. 

Mr. SCOTT. One small question? 

Mr. PAYNE. We are invaded already by folks trying to get in. 

They have to have this room cleared and ready for the new group. 
78

Mr. SCOTT. 30 seconds. 

Mr. PAYNE. All right, 15. 

Mr. SCOTT. 15 seconds. How do we address the B, be faithful, 

while at the same time addressing the point that Dr. Mukherjee 

said about the circumstances economically in this region, where 

men, huge numbers of men, are asked to go away from there? Be 

faithful, it is a standard of six, 7 months at work in the mines. 

Is there an application for that in your—and I am with you on 

the be faithful and the changing of behavior. But how do you deal 

with that? Is there something we can do with that? 

Dr. HEARST. Well, I don’t have a 30-second solution to that, but 

you absolutely have to look at—it is not just a matter of preaching 

at people; you have got to give them a reality-based option for what 

they can be doing instead. 

Mr. PAYNE. Thank you very much. We would like to even know 

how we can actually evaluate abstinence and faithful programs. 

You know, there is very little research done on which ones are 

working, and where, but we don’t have time to ask that question. 

I am sure some of you have some ideas on it. 

But let me just thank the panel again. This has been very, very 

helpful, as we could certainly even go on further and all. We have 

a lot of work to do. You have to remember that back in 1980, when 

HIV and AIDS first came, was first detected, 1979, $50,000 was allocated for it. That was national, international; it was something 

no one wanted to deal with, no one wanted to be bothered with. 

And actually, believe it or not, Secretary of State, at that time, 

Colin Powell, was going to announce $250 million that the U.S. was 

going to have as a pledge when the HIV/AIDS question first came 

up. And we certainly had a discussion about, you really weren’t serious about that was what the administration was going to do. 

And it was really the help from the evangelical community that 

got the ear of the President and talked about primarily ARVs. It 

was really the mother-to-child transmission that caught the attention of the evangelical community. And that was the community 

that really changed the focus, because the White House abolished 

the Office on HIV and AIDS that was in the White House under 

the Clinton administration was abolished. 

However, thank God for the evangelical community that came 

forth and said we have got to stop this mother-to-child transmission. They were very pro-life people. And that started the ball 

rolling in the White House, to where we saw a quantum leap in 

the fact that this was something that had to be done. 

And so the prevention went on. There was really no interest in 

trying to do treatment. And I think one of the, unfortunately for 

a gentleman who was going for the USAID job said, you know, 

well, Africans can’t tell time, so he was told well, we can’t spend 

money on treatment, so he came up with a very illogical statement, 

which he certainly had indicated that he was sorry that he made 

such a statement. But it was because no one wanted to get involved 

in treatment, it was too expensive, you know. 

But we are in a new day. I have to certainly commend President 

Bush and the Congress for accepting the $15 billion that he recommended. Hopefully we will be able to do the $30 billion, but I 

might have to put a $20 billion rider to satisfy our good friend. We 
79

need to fund TB, the MDX and XDRs, no question. There is funding for malaria. And so if we can increase the funding for those, 

maybe we can indirectly get the $50 billion, and we will move forward. 

But let me thank all of you for this very important hearing. We 

do have, for the record, we received a written statement from the 

Center for Health and Gender Equity, and it will be included in the 

record without opposition. 

[The information referred to follows:]

STATEMENT SUBMITTED FOR THE RECORD BY SERRA SIPPEL, ACTING EXECUTIVE

DIRECTOR FOR THE CENTER FOR HEALTH AND GENDER EQUITY (CHANGE) 

Chairman Lantos, distinguished Members of the House Committee on Foreign Affairs, and Committee Staff, first let me thank you for holding this hearing on such 

an important matter. The Center for Health and Gender Equity is a U.S.-based nongovernmental organization focused on the effects of U.S. international policies on 

the health and rights of women and girls in developing countries. We believe that 

every individual has the right to the basic information, technologies and services 

needed to make informed choices about their sexual and reproductive health. On behalf of the Center for Health and Gender Equity, I am pleased to provide this testimony regarding the direction of the President’s Emergency Plan for AIDS Relief as 

we move forward with reauthorization in 2008. 

The President’s Emergency Plan for AIDS Relief is about to reach its 5-year mark. 

As we reflect on the inception of this monumental effort, it is necessary to assess 

how far we have come and how far we have to go. HIV/AIDS is a pandemic that 

is ravaging female communities across the globe and in this next phase of PEPFAR 

the United States has the opportunity to establish comprehensive and integrated 

HIV prevention strategies that address the specific vulnerabilities of women and 

girls in each country receiving U.S. assistance to combat HIV/AIDS. 

Today, 80 percent of HIV infections are sexually transmitted. Women represent 

more than 50 percent of those infected with HIV worldwide. In sub-Saharan Africa 

alone, women account for 60% of those living with the virus, and 76% of people aged 

15–24 who are living with the virus are female. Additionally, 500,000 women die 

each year from pregnancy-related complications, and 200 million women have an 

unmet contraceptive need. High rates of illness and death related to sex and reproduction are rooted in the stark gender disparities that characterize women’s lives 

throughout much of the world. These include lack of access to education, income, 

property, and other productive resources, and social, legal and cultural norms that 

limit women’s control over sex and reproduction, and contribute to high rates of violence against women and girls. 

In order to adequately address this bourgeoning epidemic among women, PEPFAR 

must position itself to integrate services like reproductive health, family planning, 

and HIV/AIDS. This integration will create opportunities for PEPFAR to expand its 

impact in target countries by moving PEPFAR-funded programming toward comprehensive prevention, care, and treatment of women and girls to reduce their 

vulnerabilities to HIV infection. 

INTEGRATION ASSISTS PEPFAR IN MEETING GOALS AND TARGETS

Integration of reproductive health interventions with HIV prevention and treatment interventions is a key component to meeting the goals of PEPFAR and provides an avenue to ensure long-term success in the global fight against HIV/AIDS. 

Not only would integration of programs help prevent and reduce HIV infections 

among women and girls, but it would also help prevent HIV transmission from 

mother to child and support HIV-positive women’s reproductive rights and fertility 

choices. Reproductive health and HIV/AIDS services are generally funded and operate separately. Therefore, clients in need of both services must see different providers for each service. This is extremely problematic for women and girls living in 

resource-poor countries. Integrated programming further promotes and expands access to HIV/AIDS services, while also helping to address broader public health 

issues like the shortage of healthcare workers. 

Providing both reproductive health and HIV services together, as well as addressing the social and economic factors that put women at risk of violence and make 

them vulnerable to HIV infection, would not only better serve both providers and 

clients, but would also create a more comprehensive, cost-effective, and efficient way 

of providing the services. 
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INTEGRATION ASSISTS PEPFAR IN ADDRESSING GENDER ISSUES

The Office of the Global AIDS Coordinator (OGAC) has continuously articulated 

an increased commitment to reach women and girls with prevention, care, and 

treatment services. Both reproductive health/family planning and HIV service areas 

share the same audience. This is especially true in countries with high incidence 

among women and girls of reproductive age. Through integration of these services, 

PEPFAR could increase access to programs and services for women and girls vulnerable to HIV/AIDS, while helping ensure overall sexual and reproductive health. Integrated programming would also help to reduce the stigma associated with attending stand-alone HIV/AIDS service points and negotiating condom use in a relationship. If PEPFAR is indeed moving toward a model for sustainability, it makes sense 

to integrate reproductive health and HIV/AIDS services. This claim is even stronger 

considering the commitment of OGAC to address gender issues under PEPFAR programming. 

With reauthorization, PEPFAR needs to further prioritize women and girls and 

clear targets must be developed to reduce the rates of HIV infection among this population. Resources need to be targeted to end violence, sexual coercion, trafficking, 

stigma and discrimination. Through appropriate training, health professionals specializing in integrated programs with family planning and HIV/AIDS should also be 

trained to screen for violence and coercion. This model will make for an even more 

comprehensive model addressing the special circumstances of women impacted by 

HIV/AIDS. 

INTEGRATION WILL ASSIST IN LINKING CONTRACEPTIVE USE AND HIV PREVENTION

More than 200 million women in the developing world lack access to modern contraceptives. Satisfying this unmet need will have an important impact on HIV outcomes. Increasing funding for contraceptives, including both male and female 

condom procurement and support programs required to ensure their effective and 

consistent use, would dramatically affect the prevalence of HIV/AIDS in PEPFAR 

countries. Also, research and development of new prevention technologies, like 

microbicides, is critical and holds great promise in stemming the HIV/AIDS pandemic. 

Contraceptive scale-up can offer women resources that will help them prevent 

mother to child transmission of HIV/AIDS, while also assisting in other family planning/reproductive health needs. In order to reduce HIV-infected births, infant and 

child mortality, children orphaned by HIV/AIDS, and maternal mortality, integrating family planning and reproductive health with prevention of mother-to-child 

transmission and antiretroviral therapy/treatment programs makes sense. Both HIV 

positive and HIV negative women in PMTCT programs should receive access to contraception, including appropriate counseling in order to make informed choices 

about their reproductive health. This should include counseling about contraceptive 

use as well as negotiation for safer sex. 

INTEGRATION AS A MEANS FOR SUSTAINABILITY

The United States Government has taken important steps in order to move 

PEPFAR toward sustainability. However, more must be done in order to create incentives for PEPFAR teams to support innovative integration mechanisms and approaches. In order to develop models for truly comprehensive programs PEPFAR 

must include broader determinants of vulnerability in its strategies to address the 

HIV/AIDS pandemic among women and girls. Integrating services like family planning and gender-based violence screening into HIV/AIDS services is a start. 

Information must also be disseminated outlining the appropriate implementation 

of integrated programs to PEPFAR teams and partners. Thus far, PEPFAR programs have fallen short of addressing the linkages between HIV and reproductive 

health, while also avoiding the promotion of reproductive health as a part of HIV 

prevention. Funding restrictions like the Mexico City Policya policy mandating that 

no U.S. family planning funding can be provided to any foreign nongovernmental 

organization that uses its own, non-US funds to provide abortion-related counseling, 

information or services—has only undermined PEPFAR’s ability to offer comprehensive approaches to HIV prevention programming due to a lack of precise implementation and guidance and has also harmed efforts to integrate services due to an 

over-interpretation of the application of the policy. A repeal of the Mexico City Policy would ensure integrated programs under PEPFAR are effective and reach those 

most in need of services. 

A growing body of evidence supports the integration of HIV services with family 

planning and reproductive health services. We are hopeful that Congress and the Of-
81

fice of the Global AIDS Coordinator will take heed to this evidence and work with 

us in moving PEPFAR toward a true model for sustainability. Integration will aid 

in expanding access to much-needed treatment, care and prevention services to 

women who need them the most, while also efficiently using health professionals and 

health systems in a manner that is the most cost-effective. Lastly, integration will 

contribute to a long-term, sustainable model that broadly addresses HIV/AIDS 

amongst one of the most vulnerable and hardest hit populations impacted by the 

pandemic. 

The Center for Health and Gender Equity asks that you consider our testimony 

as you deliberate over the reauthorization of the President’s Emergency Plan for 

AIDS Relief in the coming months. Should you have any questions or comments, feel 

free to contact me or Jamila Taylor, Legislative and Policy Analyst, The Center for 

Health and Gender Equity, 6930 Carroll Avenue, Suite 910, Takoma Park, MD 

20912; (301) 270–1182; jtaylor@genderhealth.org. Thank you very much.

Mr. PAYNE. Once again, thank you all very much. This was extremely helpful and very interesting. Thank you very much. 

The meeting is now adjourned. 

[Whereupon, at 1:50 p.m., the committee was adjourned.] 

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A P P E N D I X 

MATERIAL SUBMITTED FOR THE HEARING RECORD

PREPARED STATEMENT OF THE HONORABLE SHEILA JACKSON LEE, A REPRESENTATIVE

IN CONGRESS FROM THE STATE OF TEXAS

Mr. Chairman, thank you for convening today’s important hearing. It is estimated 

that HIV/AIDS, tuberculosis (TB), and malaria together kill more than 6 million 

people each year. In January 2003, President Bush announced the President’s 

Emergency Plan for AIDS Relief, or PEPFAR. As its name implies, PEPFAR was 

envisioned as an emergency response; we are here today to discuss how to transition 

to a sustainable program to address these global epidemics. May I take this opportunity to thank the Committee’s ranking member, and to welcome our four distinguished witnesses: Helene Gayle, MD, MPH, President and CEO, CARE, USA; Joia 

Stapleton Mukherjee, MD, MPH, Medical Director, Partners In Health and Assistant Professor of Medicine, Harvard University; Nils Daulaire, MD, MPH. President 

and CEO, Global Health Council; and Norman Hearst, MD, MPH, Professor of Family and Community Medicine and of Epidemiology and Biostatistics . University of 

California, San Francisco (UCSF), School of Medicine. I look forward to your testimony. 

Seventeen years after the first cases were diagnosed, AIDS remains the most relentless and indiscriminate killer of our time, with 39.5 million people worldwide 

now living with HIV or AIDS. Despite pouring billions and billions of private and 

federal dollars into drug research and development to treat and ‘‘manage’’ infections, 

HIV strains persist as a global health threat by virtue of their complex life cycle 

and mutation rates. 24.7 million of those infected, or about 63%, live in Sub-Saharan Africa, a region with just 11% of the world’s population. 61% of those infected 

in this region are women. Though Africa, and even more specifically African women, 

bears the brunt of the AIDS pandemic, Americans should be reminded that HIV/

AIDS does not discriminate, with well over a million people in our own country currently living with HIV or AIDS. 

Tragically, 6% of the 39.5 million people currently infected with HIV/AIDS are 

children under 15 years of age. In 2006, the virus killed 380,000 children (13% of 

all HIV/AIDS deaths), and 90% of all children living with HIV reside in sub-Saharan Africa. According to UNAIDS statistics from 2005, 1,500 children worldwide became newly infected with HIV every singly day, due largely to inadequate access 

to drugs that prevent the transmission of HIV from mother to child. Only 8% of 

pregnant women in low- and middle-income countries were offered services to prevent HIV transmission to their newborns. 

Mr. Chairman, HIV/AIDS continues to represent a serious and large-scale challenge throughout much of the world. It goes far beyond a simple health problem, 

and it hinders attempts to foster economic development and political stability. As 

we begin the process of reauthorizing PEPFAR, I believe it is crucial that we emphasize the long-term sustainability of our HIV efforts, and that we integrate AIDS 

prevention and treatment within our larger-scale development initiatives. 

Though we have drugs that are effective in managing infections and reducing 

mortality by slowing the progression to AIDS in an individual, they do little to reduce disease prevalence and prevent new infections. For this reason, there is growing consensus among health experts that we must put greater emphasis on prevention programs, which are perhaps the most critical aspect of any initiative to combat 

global HIV/AIDS. Even as increasing numbers of people have access to antiretroviral drugs (ARVs), an estimated 5.1 million people who needed treatment did 

not receive it in 2006. In sub-Saharan Africa, the percentage of individuals needing 

treatment who actually received it rose substantially, from 2% in 2003 to 28% in 

2006. This growth is impressive, and represents a significant step forward, but it 
84

also means that 72% of sub-Saharan Africans requiring treatment did not receive 

it. 

Mr. Chairman, despite our concerted efforts, we continue to face a serious and 

persistent health threat. I believe that it is imperative that we ensure that American taxpayer dollars are used to greatest effect, not to bolster ideology. Current restrictions on PEPFAR mandating that 1/3 of all prevention funds must be used on 

abstinence-only education neglect the real needs of populations both in America and 

abroad. These stipulations hurt the ability of PEPFAR to adapt its activities in accordance with local HIV transmission patterns, and they impair efforts to coordinate 

with national health plans. Though AIDS is clearly a global problem, it does not affect every nation equally or in the same manner. Removing these stipulations would 

allow PEPFAR to better address the requirements of each country, making more efficient and effective use of taxpayer dollars in serving the millions affected by this 

disease. 

In addition, I believe it is crucial that we dedicate greater attention to strengthening local health infrastructure. Health experts have expressed concern that the 

high amount of spending directed toward HIV/AIDS initiatives has drawn health 

workers away from public health facilities and other important programs. This 

merely compounds a chronic shortage of qualified health workers, which, according 

to WHO’s 2006 World Health Report, is the single most important health issue facing countries today. This need is felt particularly sharply in Southeast Asia and subSaharan Africa. 

Many health experts also continue to advocate greater integration between 

PEPFAR and other health programs, including those focused on nutrition, maternal 

and child heath, and other infectious diseases. These experts note that HIV is intricately linked to these other areas of concern; for example, malnutrition and lack of 

food may heighten exposure to HIV, raise the likelihood of engaging in risky behavior, increase susceptibility to infection, and complicate efforts to provide antiretroviral (ARV) medication. Further, an HIV epidemic will likely worsen food insecurity, by depleting the agricultural workforce. I believe it is necessary, to ensure 

maximum effectiveness, that we integrate PEPFAR with other aspects of our international health outreach and development programs. 

Mr. Chairman, if we are to turn the tide of turmoil and tragedy that HIV/AIDS 

causes to millions around the world, and hundreds of thousands right here in our 

backyard, it is imperative that we continue to fund and expand medical research 

and education and outreach programs. However, the only cure we currently have 

for HIV/AIDS is prevention. While we must continue efforts to develop advanced 

treatment options, it is crucial that those efforts are accompanied by dramatic increases in public health education and prevention measures. Investments in education, research and outreach programs continue to be a crucial part of tackling and 

eliminating this devastating disease. 

As Americans, we have a strong history, through science and innovation, of detecting, conquering and defeating many illnesses. We must and we will continue to 

fight HIV/AIDS until the battle is won. 

Thank you, Mr. Chairman. I yield back the balance of my time. 

PREPARED STATEMENT OF THE HONORABLE CHRISTOPHER H. SMITH, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY

Thank you, Mr. Chairman, for calling this timely hearing in anticipation of the 

reauthorization of the President’s Emergency Plan for AIDS Relief. In the short four 

years of its existence, PEPFAR has transformed the nature of this pandemic. In 

2003, HIV/AIDS was a ravaging death sentence that was destroying individuals, 

families and entire communities. Now, it is an ongoing crisis that, while still to be 

feared, can be restrained if it is addressed through sufficient resources and appropriate, evidence-based policies. 

Although anti-retroviral treatment has been pivotal in slowing the tide of the pandemic, we cannot rely on ARVs as the centerpiece of a sustainable program. As we 

will hear during today’s testimony, for every person who is placed on ARVs, there 

are six new infections. So we must focus our efforts on learning what has worked 

up to now in reducing the prevalence rates of HIV/AIDS and concentrate our resources on expanding those successful strategies. 

Prior to PEPFAR and the implementation of the 33 percent prevention spending 

requirement on abstinence and be faithful programs, almost no one—USAID included—even considered devoting resources to these measures. I am told that some 

USAID personnel in the field even laughed at the idea of abstinence training when 

PEPFAR was first being implemented. Most—if not all—of HIV/AIDS prevention 
85

programming consisted of condom marketing and distribution. Yet as we will hear 

from our distinguished witness Dr. Norman Hearst, the condom approach did not 

work in countries where the pandemic is spread among the general population and 

which constitute the majority of the world’s infections. 

The PEPFAR comprehensive, evidence-based approach adopted the successful 

ABC model that originated in Uganda, and the success of reducing HIV prevalence 

rates through sexual behavioral change is being replicated in other PEPFAR focus 

countries. This approach is showing other positive outcomes as well. For example, 

a PEPFAR-funded program at Chibelo Basic School in Zambia emphasizes abstinence as part of a holistic, lifeskills training program. Since the program was implemented two years ago, the number of pregnancies among the 520 school girls 

(grades 5–9) has dropped from 13 in 2003–2004 to zero so far this year. School management also attributes the program with significantly enhancing academic performance. 

I have been deeply disturbed by the insinuations of some that sexual behavioral 

change is not possible for Africans. Fr. Thomas Williams, in a May 17, 2007 article 

in the National Review, notes that he has spoken to numerous Africans who find 

the Western supposition that ‘‘they’re going to do it anyway’’ to be not only insulting, but racist. He notes that ‘‘prejudice against Africans with no self-discipline or 

control over the sex drive simmers just beneath the surface of much anti-abstinence 

propaganda.’’

On the other hand, the question is appropriately raised as to why those who consider themselves ‘‘experts’’ are refusing to accept the evidence about the success of 

behavioral change, and if they do accept the evidence, why are they opposed to the 

AB spending requirement. With the spending requirement, the United States is the 

only major international donor providing substantial support to this proven prevention strategy. Without it, we are faced with the specter of returning to a failed 

condoms—centric approach—and to the devastating loss of human life of the prePEPFAR era. 

Finally, I am deeply concerned that some pro-abortion NGOs are attempting to 

hijack PEPFAR and other noble initiatives to promote the slaughter of unborn children in Africa and around the world. 

Pro-abortion groups are using HIV/AIDS funding as a trojan horse to facilitate 

policies that reduce unborn children to expendable commodities. 

Abortion methods are violence against children. 

Dismembering a baby with sharp knives or chemically poisoning a child with 

drugs and toxic chemicals can never be construed as benign or compassionate—it 

is child abuse. 

WRITTEN RESPONSE FROM NORMAN HEARST, M.D., MPH, PROFESSOR OF FAMILY AND

COMMUNITY MEDICINE AND OF EPIDEMIOLOGY AND BIOSTATISTICS, UNIVERSITY OF

CALIFORNIA, SAN FRANCISCO (UCSF), SCHOOL OF MEDICINE, TO QUESTIONS SUBMITTED FOR THE RECORD BY THE HONORABLE CHRISTOPHER H. SMITH, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY

Questions: 

• There was conflicting testimony during the course of the hearing as to the prevalence of HIV/AIDS in the poor as opposed to wealthy segments of any given population. What evidence are you aware of with respect to this question in Sub-Saharan Africa and other PEPFAR focus countries?

• According to your research, does the treatment of STI’s reduce the transmission 

rate of HIV/AIDS?

• To what extent does prostitution contribute to the spread of the HIV/AIDS pandemic in Sub-Saharan Africa?

• Please address any other issues that were raised during the course of the hearing 

with respect to HIV/AIDS prevention that you deem necessary to clarify. 

Response: 

As indicated by your questions, the Committee did indeed receive conflicting testimony on a few key points. At least one other witness endorsed the common but erroneous belief that HIV infection rates are higher among the poor in countries with 

generalized HIV epidemics. This is simply not true in Sub-Saharan Africa, where 

most PEPFAR priority countries are located. 

I attach a recent commentary published in The Lancet by James Shelton of 

USAID and colleagues. They present clear evidence that HIV infection rates are 

positively associated with wealth in most Sub-Saharan countries with generalized 
86

epidemics rather than being higher among the poor. They discuss possible explanations for this as well as the consequences of widespread confusion about this matter, including among many people who consider themselves to be AIDS ‘‘experts.’’ 

I will be happy to provide additional evidence about this if desired. 

Similarly, one of the panelists repeated the outdated belief that treating STI’s is 

an effective strategy for reducing HIV transmission in generalized epidemics. In 

fact, there have now been six large randomized trials to test this hypothesis. Five 

of the six showed that treating STI’s produced no reduction in HIV infection rates. 

So while treating STI’s is certainly important in its own right, it can no longer be 

considered a public health strategy for AIDS prevention. 

In addition, more than one of the panelists greatly exaggerated the importance 

of commercial and transactional sex in spreading HIV in Sub-Saharan Africa. Stories of girls trading sex for school fees have been repeated over and over. While this 

no doubt happens sometimes, quantitative epidemiologic studies consistently show 

that this situation and the ‘‘sugar daddy’’ phenomenon are much less common in Africa than commonly supposed. Commercial sex accounts for only a small proportion 

of HIV transmission in countries with generalized epidemics. 

The question here is not whether poverty alleviation, treating STI’s, and improving the status of women are important. Of course they are. The question is whether 

they are where we should put our limited AIDS prevention dollars. This decision 

needs to be based on evidence of effectiveness, not facile sociologic arguments. Are 

there credible scientific studies showing proof that poverty alleviation programs reduce HIV transmission? There are none. Are there specific examples of programs 

to improve the status of women that resulted in reduced rates of HIV? There are 

none. Are there randomized controlled trials showing that treating STI’s reduces 

HIV transmission? There is one, but there are five others that showed no such effect. 

PEPFAR must instead put its money into strategies that have been proven to be 

effective. The most notable of these was the home-grown Ugandan ‘‘Zero Grazing’’ 

approach. When Ugandans decided to tackle their AIDS problem head on in the late 

1980’s, they did not say, ‘‘We must alleviate poverty before we can control AIDS,’’ 

or ‘‘We must improve the status of women before we can fight AIDS.’’ Instead, they 

took a common sense approach based on the knowledge that HIV is sexually transmitted. They mobilized all sectors of society to get people to change their sexual behavior, and they succeeded with little outside help and very limited funding. 

PEPFAR has been a leader among international AIDS prevention programs by 

truly putting its money into ABC and not just giving it lip service while spending 

most of its prevention budget on other things. It would be foolish to change this 

without clear evidence that other approaches are more effective, not just emotional 

arguments that would divert energy and funding in unproven directions. 

Let me once again thank you for the opportunity to testify to the Committee and 

to respond to these questions.
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