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[Senate Hearing 107-407]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 107-407
 
              CAPACITY TO CARE IN A WORLD LIVING WITH AIDS
=======================================================================

                                HEARING

                               BEFORE THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                               __________

  EXAMINING ISSUES RELATED TO HEALTH CARE FOR PATIENTS WITH THE AIDS 
   VIRUS AND WHAT CAN BE DONE TO ADDRESS THE GLOBAL HIV/AIDS PANDEMIC
                               __________

                             APRIL 11, 2002

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

                       U. S. GOVERNMENT PRINTING OFFICE
78-812                          WASHINGTON : 2002
___________________________________________________________________________
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio
           J. Michael Myers, Staff Director and Chief Counsel
             Townsend Lange McNitt, Minority Staff Director

                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                             APRIL 11, 2002

                                                                   Page
Kennedy, Hon. Edward M., a U.S. Senator from the State of 
  Massachusetts..................................................     1
Clinton, Hon. Hillary Rodham, a U.S. Senator from the State of 
  New York.......................................................     1
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee.....     5
Murray, Hon. Patty, a U.S. Senator from the State of Washington..    11
Warner, Hon. John, a U.S. Senator from the State of Virginia.....    11
Dodd, Hon. Christopher J., a U.S. Senator from the State of 
  Connecticut....................................................    12
Sessions, Hon. Jeff, a U.S. Senator from the State of Alabama....    14
Thurman, Ms. Sandra L., president, International AIDS Trust, 
  Washington, DC.................................................    14
    Prepared statement...........................................    17
John, Sir Elton, chairman, Elton John AIDS Foundation, Beverly 
  Hills, CA......................................................    20
    Prepared statement...........................................    22
Mugyenyi, Peter, M.D., director, Joint Clinical Research Center, 
  Kampala, Uganda................................................    24
    Prepared statement...........................................    26
Rosenfield, Allan, M.D., dean, School of Public Health, Columbia 
  University; director, MTCT-Plus Initiative, New York, NY.......    27
    Prepared statement...........................................    30
Dortzbach, Ms. Deborah, international director, HIV/AIDS 
  Programs, World Relief International, Baltimore, MD............    32
    Prepared statement...........................................    34

              CAPACITY TO CARE IN A WORLD LIVING WITH AIDS

                              ----------                              

                        THURSDAY, APRIL 11, 2002

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:38 a.m., in 
room SD-106, Dirksen Senate Office Building, Hon. Edward M. 
Kennedy (chairman of the committee) presiding.
    Present: Senators Kennedy, Dodd, Wellstone, Murray, 
Clinton, Frist, Warner, and Sessions.

                  Opening Statement of Senator Kennedy

    The Chairman. The hearing will come to order.
    We welcome our guests this morning who bring to this issue 
the challenges that we are facing in international AIDS a 
wealth of experience and an extraordinary sense of compassion 
and a series of recommendations about how we as a country can 
be even more effective in giving this the kind of world 
priority that it deserves.
    I am going to recognize Senator Clinton, whose schedule is 
complicated, and who has been a real leader in our committee on 
this issue as she is on many other issues, and then I will say 
a word about some of my colleagues.
    Senator Frist has been a great leader. He has traveled to 
Africa a number of times and has been very much involved in 
this issue as well as in other health issues. We are obviously 
very, very grateful for his presence and involvement.
    Senator Warner has been a very active supporter of all of 
these efforts and very much wanted to have the opportunity to 
listen to our witnesses as well.
    In just a moment, I will also talk about the leadership 
that has been provided by other colleagues on other committees 
which has been so valuable and helpful, but I want to extend 
just a word of very special appreciation to the leadership that 
Senator Clinton has provided. We are enormously grateful for 
her words at this time.

                  Opening Statement of Senator Clinton

    Senator Clinton. Thank you very much, Mr. Chairman.
    I think we can tell by the number of people who are here 
that this issue has enormous impact here in our country and 
around the world, and I am very grateful to all the witnesses 
who are here and particularly pleased that my friend and 
someone who has really led with his own charitable giving, the 
effort to deal with HIV/AIDS, Elton John, could be with us 
today. I asked Chairman Kennedy if we could just put a piano in 
here, and he could sing his testimony, but we did not get that 
worked out in time--maybe the next time.
    We are also grateful to Sandra Thurman, who is president of 
the International AIDS Trust, for working in this area for so 
many years, and Dr. Allan Rosenfield from Columbia University 
in New York. And indeed, we are also grateful to Dr. Mugyenyi 
and also our last witness, Deborah Dortzbach.
    All of these people represent the most forward-looking, 
effective advocacy and practice when it comes to HIV/AIDS. I am 
delighted that this hearing is being held by this committee, 
because we know that we have to have a united effort in our 
country. I want to thank Senator Frist for working with me on a 
bill that we introduced last year which really follows up on 
the work that he has done for so many years in Africa. This 
bill would send more trained doctors and nurses and health 
professionals to countries where we could help to provide 
additional resources, both money and human, in the great 
struggle against HIV/AIDS. So I appreciate not only Senator 
Frist's leadership but his example.
    Having a trained, stable work force is one of the keys, but 
clearly, that is not enough. I would hope that the United 
States' efforts would be significant. In the United States, 
roughly 70 percent of the $10.8 billion of Federal resources 
spent on HIV/AIDS over the years has gone to care and 
treatment. Globally, the percentage of dollars spent on care 
and treatment is only 10 percent. We have to have a much 
broader range of reaction that takes into account all the 
various challenges that we confront.
    I appreciate Secretary-General Kofi Annan's call for a $10 
billion investment worldwide. I think, as a Senator who 
represents a State where we have struggled with HIV/AIDS for 
years and as someone who in the previous administration was 
privileged to go not only to Africa, but to Asia several times, 
that the United States' fair share of this effort should be 25 
percent at minimum. I do not think that we have stepped up and 
given the resources that this emergency really demands from the 
United States.
    We also have to better utilize the extraordinary expertise 
available in our Federal Government and assets in institutions 
like HHS which, through its various agencies--HRSA, CDC, NIH--
over which this committee has jurisdiction, has tremendous 
expertise that needs to be utilized. HHS has been a key partner 
in the so-called Life Initiative since it was launched, 
virtually tripling the United States' investment in 
international HIV/AIDS efforts.
    So today, we will look at the problem in light of what we 
could do, what we could do more, what we could do better, 
especially given HHS' strengths and capacities, and the 
leadership that the United States should show in addressing 
this global crisis.
    I want to thank the witnesses and many others whom I see in 
the audience who, through their hard work, their philanthropic 
efforts, and their political advocacy, have really forced this 
issue to the forefront of our agenda, and I thank you, Mr. 
Chairman, for giving us this opportunity to really focus 
national and international attention. We have a number of 
ambassadors from different countries here, many from African 
countries, and I am very pleased that they are here as partners 
in this effort.
    The Chairman. Thank you very much, Senator Clinton.
    Before recognizing others, I want to thank Senator Gregg, 
our ranking member, who is not here.
    Our leader, Senator Daschle, has given this a very high 
priority for this session of Congress. Senators Durbin, 
Corzine, Feinstein, Kerry, and Biden are members of the Foreign 
Relations Committee who have very, very important obligations 
and responsibilities in terms of serving that committee and 
also in this area. We are working very closely with them, as we 
should. And we are grateful as well to the support that Senator 
Helms has given to particularly the issues on infants and their 
various challenges.
    I will take just a very brief moment to thank our witnesses 
for being here.
    This is a pandemic that is affecting Africa, but not only 
affecting Africa--it is expanding into India, Southeast Asia, 
China, and the Soviet Union. It is something which this 
committee first held hearings on over 10 years ago, and at that 
time, the challenge that we faced as a country and as a society 
was really riddled with ideology, not science, not health 
considerations, but ideology. And it took a long time for the 
United States to begin to come to grips with this issue and 
deal with it in terms of understanding it, willingness to reach 
out to the millions of people whose lives are so devastated and 
affected by the scourge of this disease. We have made enormous 
progress, and it is a real tribute to so many who have worked 
so hard for so long in helping and assisting Congress and 
providing leadership in local communities and States as well.
    The challenge is out there in terms of the world, and the 
real challenge is will the United States really rise to this 
challenge when we have been able in the last 10 years, with the 
progress that has been made, the research that has been 
achieved, the understanding about prevention, the new 
modalities in terms of understanding the challenge that is out 
in regard to mothers and infants, the reality of understanding 
the devastation that this scourge causes countries in Africa--
we cannot exist on this planet without understanding how our 
fellow citizens are hurting, and when the United States is 
prepared to lead, what a difference it can make. We have 
already seen it; there are encouraging signs.
    This is really a wakeup call, and we have individuals on 
our panel this morning who will help us better understand it, 
and I am most grateful to all of them, as they have been 
leaders on this issue day in and day out over such a long 
period of time. They bring a wealth of understanding, a strong 
commitment, and they have been incredibly effective, so we can 
benefit greatly from them, and we look forward to hearing from 
them in just a moment.
    [The prepared statement of Senator Kennedy follows:]

                 Prepared Statement of Senator Kennedy

    Today's hearing is about the greatest global public health 
threat of our times--the spread of HIV/AIDS.
    AIDS is the fourth leading cause of death in the world. 
This terrible disease destroys lives, denies hope to 
individuals and families, and threatens the well-being of 
entire countries.
    We in America know of the pain and loss that this disease 
cruelly inflicts. Millions of our fellow citizens--men, women, 
and children--are infected with HIV/AIDS. And far too many have 
lost their lives.
    While we still seek a cure to AIDS, we have learned to help 
those infected by the virus to lead long and productive lives 
through the miracle of prescription drugs.
    But this disease knows no boundaries. It travels across 
borders to infect innocent people in every continent across the 
globe.
    We have an obligation to continue the fight against this 
disease at home. But we should also share what we have learned 
to help those in other countries in this life-and-death battle. 
And we must do all we can to provide new resources to help 
those who cannot afford today's therapies.
    This committee and its members have a deep commitment to 
sharing the lessons learned in helping our people at home to 
help others meet great human needs abroad. As we sought to 
enforce child labor laws at home, we also worked to protect 
children abroad. As we developed new ways of promoting 
children's health and public health, we have shared these life-
saving discoveries with other countries in need.
    And once again, we are called upon to open the doors 
between nations to do all we can to halt the spread of AIDS, 
and to treat those infected by it.
    Twelve years ago this month, the members of this committee 
demonstrated their commitment to the care and treatment of 
Americans living with AIDS by passing the Ryan White Care Act. 
Since that time, community-based care has become more 
available, drug treatments have improved that nearly double the 
life expectancy of HIV positive individuals, and public 
campaigns have increased awareness of the disease. Yet, 
advances such as these remain largely the privilege of wealthy 
nations.
    AIDS inflicts a special toll on developing countries. 
Globally, 40 million people have HIV/AIDS, and the overwhelming 
majority live in poor countries. Sub-Saharan Africa is the most 
affected region, where nearly all of the world's AIDS orphans 
live. AIDS robs poor countries of the workers they need to 
develop their economies. They lose teachers needed to combat 
illiteracy and train their workers for modern challenges. In 
Africa, they have lost seven million farmers needed to meet the 
food needs of entire nations. AIDS plunges poor nations into 
even deeper, more desperate poverty.
    The presence of HIV/AIDS poses a particularly serious 
concern for women and girls. Most new infections are among 
young adults and women. Females who are not infected feel the 
impact, too. Girls must often leave school to assume 
responsibilities for sick family members, robbing them of 
educational opportunities and denying local economies of 
valuable workers.
    Governments can make the difference in battling this 
epidemic. Where governments in poor countries have been 
provided resources to fight the spread of AIDS, infection rates 
have dropped 80 percent. But these countries cannot turn the 
corner on AIDS on their own. Their governments must be provided 
the guidance and resources to carry out anti-AIDS campaigns. 
They need financial help to afford expensive anti-retroviral 
drugs. And drug companies must do their part to make these 
drugs more affordable to the poor.
    In addition, more public education is needed. A UNICEF 
survey found that most young people still have not heard of 
AIDS or do not understand how the disease is transmitted. By 
speaking out, our Government can help to lift the stigma and 
taboo surrounding the disease and save lives.
    These challenges are not insurmountable. The epidemic is in 
its early stages. In most regions of the world, the prevalence 
rate is still less than 1 percent of the population. But we 
cannot delay. It only took 10 years for the HIV/AIDS population 
to double in the Russian Federation. And in South Africa, the 
rate increased from 1-in-100 people to 1-in-4 in one decade.
    Our committee is developing legislation to support and 
strengthen global treatment and training initiatives.
    Our legislation would provide new legal authority and 
funding to NIH, CDC, HRSA and the Department of Labor to join 
the global battle against AIDS.
    It would promote community-based care models and better 
access to microbicide research and retroviral therapies.
    Our legislation would fund research and treatment models to 
prevent the transmission of the disease from mothers to their 
infants.
    And it would help countries to develop better training 
models that support service delivery at the grassroots level.
    Today we will hear from witnesses who have devoted 
themselves to fighting this epidemic by ensuring that 
prevention, care, and treatment is not just accessible to some 
people in some countries, but all people in all countries.
    We are honored to have you with us today.
    The Chairman. We have been joined by Senator Sessions and 
thank him very much for joining us.
    I will now turn to Senator Frist, who has been so involved 
and has provided important leadership in this area, if he would 
say a word.

                   Opening Statement of Senator Frist

    Senator Frist. Thank you, Mr. Chairman.
    I too want to thank each of our witnesses. It is wonderful 
to be able to sit where we are and look out at the witnesses 
with whom many of us have had the opportunity to interact 
individually, but also to see the people who have come to this 
hearing today, members from the public sector, from the 
academies, from the corporate sector, from the private sector, 
from the NGOs, from the evangelical community, from the 
entertainment industry. It really points out to me the fact 
that in 2002, we have an opportunity which, as the chairman 
said, we will see if we are up to facing directly and 
appropriately, but we have an opportunity to address the 
challenge that has increased over the last 10 years and 
increased over the last 15 years, but a challenge which is much 
bigger than any of us as individuals, as Members of the United 
States Senate, as members of the U.S. Government--much bigger 
than the United States of America. It really is a global 
challenge, and the opportunity is there before us.
    This particular committee has not formally addressed this 
particular issue, and I am delighted and thank the chairman and 
the ranking member, Senator Gregg, for bringing this hearing 
before us, because we have not formally addressed it in such a 
comprehensive way in over a decade.
    Over that same decade, the number of new infections of HIV, 
if we look just in Sub-Saharan Africa, has increased from an 
increase of around 1 million a year to around 3.5 million new 
infections a year.
    We have opportunities that I think are unique for the time 
today because of the range of people involved. As Chairman 
Kennedy pointed out, the perspective was much different 10 
years ago and even 5 years ago, and as I have followed this 
issue closely over the last 5 years, I think it is much 
different than even a year or 2 years ago. Now it is our 
challenge to capture that intersection of bringing a diverse 
group of people from the breadth of the political spectrum 
together to address an issue that is much greater than any of 
us.
    I want to thank my colleague Senator Jesse Helms who, over 
the last 2 weeks, rightly said that we have within our power 
the ability to substantially reduce the mother-to-child 
transmission of HIV/AIDS, something that our panel will address 
this morning. Senator Helms has pledged to do just that, and I 
intend to join him in those efforts.
    President Bush, Secretary of State Colin Powell, and 
Secretary Thompson of HHS are also committed to aggressively 
fighting the global AIDS epidemic.
    With the commitment of our Nation's leaders and, as we will 
talk about this morning, the critical importance of having 
world leaders from other nations, both affected as well as 
donor nations, I believe we can stand up to this challenge.
    With that, Mr. Chairman, I will stop. I think that issues 
and the importance of science will come forward. In the 
meantime, we have a lot to do as we wait for that vaccine. We 
do not even know if we are going to have that vaccine, and we 
have a lot to do.
    Let me just say thank you, Mr. Chairman, for calling the 
hearing, and I look forward to hearing from our witnesses.
    [The prepared statement of Senator Frist follows:]

                  Prepared Statement of Senator Frist

    Mr. Chairman, thank you for calling this hearing. Senator 
Clinton, I appreciate your efforts to assure that the HELP 
Committee once again examines the global impact of HIV and 
AIDS. It has been over a decade since this committee looked at 
the topic of global HIV/AIDS, and it is critical that we 
continue to highlight the impact of this disease on our global 
community. This is not strictly an American problem--it ignores 
national borders, threatening the entire world.
    When I first came to the Senate 8 years ago, my aim was to 
serve my home State of Tennessee and this great Nation. Since 
arriving, my steps have also taken me far from the Senate 
floor--on seven different medical mission trips to Sudan, 
Africa, and most recently, in January, to Uganda, Kenya and 
Tanzania.
    The trips were to learn more firsthand about the impact 
that a simple virus is having on the destruction of a 
continent. Not a family. Not community. Not a state. Not a 
country. But an entire continent.
    The statistics of this global plague are shocking. Each 
year, 3 million people die of AIDS. Someone dies from the 
disease every 10 seconds. About twice that many, 5.5 million--
or 2 every 10 seconds--become infected. That's 15,000 a day. 
And what's even more tragic is that 6,000 of those infected 
each day are young--between ages 15 and 24. Ninety percent of 
those infected do not know they have the disease. There is no 
cure. There is no vaccine. And the number of people infected is 
growing dramatically.
    The disease's toll is incalculable. Thirteen million 
children have been orphaned by AIDS. Over the next 10 years, 
the orphan population may well grow to 40 million--equivalent 
to the number of American children living east of the 
Mississippi River.
    As ranking member of lthe African Affairs subcommittee of 
the Foreign Relations Committee, I have a commitment to 
increase public awareness of the HIV pandemic in Africa, and 
most importantly, to develop a strategy to combat and eradicate 
the disease. What I saw and learned in Uganda, Kenya and 
Tanzania was extraordinary--coming face-to-face with the human 
tragedy of HIV/AIDS, and lives cut far too short.
    Africa has lost an entire generation. In Nairobi, Kenya, I 
visited the Kibera slum. With a population of over 750,000, 1 
out of 5 of those who live in Kibera are HIV/AIDS positive. As 
I walked the crowded pathways sandwiched between hundreds of 
thousands of aluminum shanties, I was amazed that there were 
only children or elderly individuals. The disease had wiped out 
the parents--the most productive segment of the population--
teachers, military personnel, hospital workers, law enforcement 
officers.
    In Arusha, Tanzania, I met Margaret who developed her first 
symptoms in 1990. When her husband died, despite her illness, 
she found the strength to fight his family to keep the family 
property. Thanks to her brothers, she has a house for her 6 
children. I also met Nema in Arusha. She sells bananas to 
survive and provide for her year-and-a-half old son, Daniel. 
When Daniel cried from hunger, Nema kissed his hand because she 
had nothing else to give him but her love.
    I had the privilege of visiting with Tabu, a 28 year old 
prostitute, who was leaving Arusha to return to her village to 
die. She stayed an extra day to meet with us, and I will never 
forget her cheerful demeanor and mischievous smile as we met in 
her small stick-framed mud hut, no more than 12 by 12. Her two 
sisters are also infected, another sister has already died. 
Tabu will leave behind an 11-year-old daughter, Adija.
    At home in Tennessee, or even here in Washington, DC., 
Uganda and Tanzania feel very far away. But the plague of HIV/
AIDS and the chaos, despair and civil disorder it perpetrates 
only leads to the demise of democracy in a country, in a 
continent, in the world. Without civil institutions, there is 
disorder.
    Last year in South Africa, one of every 200 teachers died 
of AIDS. In a recent study in Kenya, 75 percent of deaths on 
the police force are AlDS-related. HIV-related deaths among 
hospital workers in Zambia have increased 13 times in over a 
decade. The aftermath of these losses is devastating to local 
economies. Botswana's economy is projected to shrink by 30 
percent in 10 years; Kenya's by 15 percent. Family incomes in 
the Ivory Coast have declined by 50 percent, while health care 
expenditures have risen by 4,000 percent.
    African orphans lack teachers, lack role models and 
leaders. This leaves them vulnerable to criminal organizations, 
revolutionary militias, and terrorists. Terrorism and crime 
could become a way of life for a young generation.
    Africa is not alone. India, with over 4 million cases, is 
on the edge of explosive growth. China is estimated to have as 
many as 10 million infected persons. The Caribbean suffers from 
one of the highest rates of infection of any region in the 
world. Eastern Europe and Russia report the fastest growth of 
AIDS cases.
    That is why I'm devoting much of my time to this issue, and 
in particular, to the impact of HIV/AIDS in Africa. Just as our 
great Nation is the leader in the war on terrorism, we must 
continue to lead the fight against AIDS in order to build a 
better, safer world.
    So, where do we go from here? There are three keys to 
combating this epidemic--(1) Leadership; (2) Prevention and 
Treatment; and (3) Funding.
    As a first step, it takes strong leadership at all levels, 
and this must come first from the top. President Museveni in 
Uganda has not been bashful about speaking very publicly to the 
citizens of his country about HIV/AIDS. Bakili Muluzi, 
President of Malawi told me that he opens every speech to his 
countrymen with an admonition about HIV/AIDS. These leaders are 
acting to bring the disease into the light, to eliminate the 
stigma sometimes associated with the disease. Others are 
acting--governments, the United Nations, the World Bank, world 
leaders, corporations and philanthropies. From President Bush 
to Kofi Annan and Secretary Powell, world leaders have 
recognized the call to action and the need to do more.
    It is also leadership from people such as Bono, lead singer 
of the Irish rock band, U2. With his passion for Africa and his 
``bully pulpit'' as a celebrity, he's a credible and 
accomplished spokesperson on the issue. He joined us in Uganda 
and Kenya for a couple of days, and I was impressed with his 
knowledge, his commitment, and his caring.
    It takes leadership at all levels to ensure that our 
efforts are well coordinated, understanding the importance of 
the diverse stakeholders in the fight against HIV/AIDS. We must 
coordinate within and across national govennments. We must 
leverage our precious resources and avoid duplication of 
effort. As I saw firsthand in east Africa, the best ideas often 
come from those fighting this disease on the ground. Community 
participation is essential, and local leadership is critical, 
particularly as we work to prevent and treat the disease. Let 
me cite a couple of examples.
    In Tanzania, Sister Denise Lynch runs the Uhai Center for 
the Roman Catholic Diocese of Arusha, serving village schools 
and churches. Father Bill Freida, a physician at St. Mary's 
Hospital in Kenya, tells me they serve over 400 HIV/AIDS 
patients a day, and their chapel and bakery help anchor the 
community. Dr. Ebenezer Mwasha, in Tanzania, teaches the 
spiritual and moral values in addition to proper health and 
hygiene. The work that these individuals have accomplished, 
coupled with their faith and commitment, are a true 
inspiration. Their efforts will pay dividends for many in the 
years to come. Their leadership on the ground and in the 
trenches, each and every day, is fundamental to our ultimate 
success.
    We should also salute the leadership of the Centers for 
Disease Control and Prevention (CDC) and the United States 
Agency for International Development (USAID). According to 
President Museveni, our Government's investment in Uganda of 
$120 million over the last 10 years has been the key to 
bringing HIV/AIDS prevalence rates down from 14 percent to 8 
percent. The presence of these agencies is making a difference.
    Until science produces a vaccine, prevention through 
behavioral change and awareness is the key. And once again, 
cultural stigmas must be overcome. Through a combination of 
comprehensive national plans, donor support and community-based 
organizations, we can make progress. Uganda, Thailand and 
Senegal are three examples of solid success.
    We must encourage people to be tested. This is an 
opportunity to save countless lives. The more people know, the 
more likely they are to act. We should increase investments in 
rapid HIV testing kits and counseling. Access to these tools 
reinforces prevention messages and guides treatment options. As 
I saw in Africa, testing centers become centers of hope, a 
place where those struggling with HIV/AIDS support each other, 
learn coping strategies, and receive medical treatment and 
nutritional support.
    I was particularly impressed by the work in the Kibera slum 
of Nairobi at the Kibera Self-Help Programme, run by the CDC. 
Officials there told me that a negative test provides a 
powerful incentive to stay healthy, and gives an opportunity to 
counsel people on risky behavior, ultimately saving lives. A 
positive test removes the burden of uncertainty and allows for 
timely treatment and counseling, an important first step in 
living longer and healthier lives.
    In recent months, pharmaceutical companies have sent a 
message of hope by slashing prices on anti-retrovirals for poor 
countries. Other treatment regimens may make an even bigger 
difference in extending life and holding families together. 
Just as importantly, treatment provides the hope people need to 
get tested. And there are other public health advantages to 
treatment that require further research and evaluation. 
Treatment with anti-retroviral drugs may lower the amount of 
virus in the blood, potentially decreasing the risk of 
transmission, both among adults and mother-to-child 
transmissions.
    In addition, access to treatment and drugs is also needed 
for opportunistic infections, such as tuberculosis (TB) and 
malaria. For all the damage caused by HIV/AIDS, TB kills more 
people in Africa with AIDS than any other opportunistic 
infection. CDC officials in Kenya told me that TB has increased 
six-fold in the last 10 years, and it's impossible to separate 
HIV and TB. I've seen first hand in Sudan the re-emergence of 
TB in strains more resistant, more virulent, than any we have 
seen before. Malaria is also more rampant in the 
immunosuppressed. Additionally, in treating severe anemia that 
commonly accompanies illness due to malaria, untested blood 
transfusions make possible additional HIV/AIDS spread.
    Let me add that on the subject of vaccines we must continue 
to search for the tools to reverse the spread of HIV/AIDS. 
Research and development must continue, and I'm pleased to 
report that NIH currently has over two dozen vaccine candidates 
in the pipeline. Someday, and hopefully very soon, we will have 
a vaccine to prevent this disease.
    Finally, support of health care delivery systems--with a 
special emphasis on personnel training--is essential to 
effective treatment programs. This fundamental principle is 
captured in my legislation--``the Global Leadership in 
Developing an Expanded Response or GLIDER Act,'' which I 
introduced last year along with Senator Clinton. The 
legislation establishes the Paul Coverdell Health Care Corps--a 
corps of health care professionals to assist in the development 
of health care infrastructure by training local individuals. 
The overall design of the Corps is such that health care 
professionals throughout their career can have a wide variety 
of opportunities to suit their training.
    In sum, I believe there are eight goals we must pursue in 
this global fight:
    1. We must continue to encourage the political, religious 
and business leaders of the world to unite against the spread 
of HIV/AIDS and to help those who are afflicted with the 
disease.
    2. We must continue to embrace the new Global Fund for HIV/
AIDS, TB, and Malaria. This is not a UN fund, or an American 
fund. It is a new way of doing business. As an additional show 
of American support, I am joining Senator HELMS in introducing 
an amendment to the Emergency Supplemental Appropriations Bill 
to provide an additional $500 million to prevent mother-to-
child transmission of AIDS. These funds would be given to the 
Secretary of State, who can spend them on bilateral programs 
and/or give them to the Global Fund for HIV/AIDS, Tuberculosis, 
and Malaria. The funds would have to be matched by non-
governmental sources.
    3. We must leverage America's resources and talent. There 
must be a ``call to cure'' for our health care professionals to 
use their talent and expertise.
    4. We must encourage and empower coalitions of governments, 
multi-lateral institutions, corporations, foundations, 
scientific institutions and NGO's to fill the gap between the 
available resources and the unmet needs for prevention, care 
and treatment.
    5. We must continue to put community-based organizations, 
both religious and secular, at the forefront by getting funds 
to them quickly so they can most effectively reach those who 
most need help.
    6. We must ensure that: international research efforts on 
disease affecting poor countries is reinforced in a manner that 
assures the best scientific work in the world will lead to real 
benefits for the developing world--at a cost they can afford.
    7. We must focus on prevention, and support care and 
treatment options that combine reasonable cost pharmaceuticals 
with appropriately structured health care delivery systems.
    8. Finally, we must provide comfort to the families and 
orphans affected--to give them hope and dignity.
    I can still hear young Daniel's cries of hunger and know 
that his young mother will not live to see him grow into 
adolescence, much less manhood; can see Sister Denise as she 
patiently and capably answers my many questions about the best 
ways we can help; still hear the pride in Father Freida's voice 
as he describes his hospital as a place to provide dignity and 
comfort to the inflicted and dying; and I think of Tabu who has 
returned to her home village to face death. These images will 
remain with me; they strengthen my resolve to win the fight 
against HIV/AIDS.
    History will judge how we as a Nation--how we as a global 
community--address and respond to this most devastating and 
destructive public health crisis we have seen since the bubonic 
plague ravaged Europe over 600 years ago.
    The task looms large, but by pulling together, with 
leadership from all--we will eliminate the scourge of HIV/AIDS 
from the face of the globe in our lifetime.
    The Chairman. Thank you.
    I will ask each of my colleagues if they want to say a 
brief word.
    We welcome Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Thank you very much, Mr. Chairman.
    Let me really thank all of our witnesses for being here 
today. It is so clear that your commitment to fighting the 
global AIDS epidemic and your work in developing a 
compassionate and humane response really has made a difference, 
so I truly want to thank all of you.
    Mr. Chairman, this is such an overwhelming issue, I think, 
for all of us. When you look at the number of people living 
with AIDS, the number of children living with AIDS, the people 
we have lost because of AIDS, it is staggering. But when you 
add the number of children who are living without a parent or 
parents, it becomes just overwhelming.
    So I think it is very clear that we need a global response 
to this growing crisis, and the United States cannot remain 
passive on this issue.
    So I really appreciate your holding the hearing today. I 
look forward to the testimony of all of our witnesses and to 
working with all of you to respond to this crisis.
    The Chairman. Thank you.
    Senator Warner.

                  Opening Statement of Senator Warner

    Senator Warner. Thank you, Mr. Chairman.
    I joined this committee because my father was a medical 
doctor and devoted much of his life to the care of those 
suffering and also to medical research.
    I wish to commend you, Chairman Kennedy, Senator Clinton, 
Senator Frist, for spearheading the interest here in the United 
States Senate. I would take it a step further than my good 
friend to my left, that it is not a challenge, but it is an 
obligation for the Congress of the United States to be a full 
partner in this effort.
    I welcome the distinguished panel of witnesses today. You 
have given much of your private and professional lives to this 
endeavor.
    I want to mention, Sir Elton, that a mutual friend of ours, 
a longstanding friend of mine, Elizabeth Taylor, has done a lot 
of work in this area, and I get frequent calls on this issue 
from her.
    But I have another reason that interests me. My work here 
in the Senate is largely in national security and international 
security, and quite frankly, this disease has had a direct 
impact on many nations in Africa to be able to maintain 
internal political and military stability and political and 
military stability with their neighboring nations. This disease 
has spread to the point where they are unable to recruit and 
maintain the necessary armed forces in these respective nations 
to secure their borders and otherwise.
    So we must address this problem here at home, and we must 
address it worldwide, and the Senate, I hope, with the Congress 
as a whole will be a full partner.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much.
    Senator Dodd.

                   Opening Statement of Senator Dodd

    Senator Dodd. Mr. Chairman, I would ask unanimous consent 
that my opening remarks be included in the record.
    I want to thank Senator Clinton and Senator Frist and 
others for holding today's hearing. Last evening, in fact, Mr. 
Chairman, I co-chaired along with our colleague Senator DeWine 
the Elizabeth Glaser Pediatric AIDS Foundation dinner, where 
Morty Barr of the Communication Workers and our colleague Orrin 
Hatch were honored last evening.
    To try to get this in perspective, the numbers get so 
overwhelming that it becomes very difficult, I think, for 
average people to get a sense of the magnitude of the problem. 
But I was struck, going over some of the numbers yesterday in 
preparation for some brief remarks last evening, that if 
everyone here just today, as we go through our normal daily 
work today with our hearings and meetings and whatever else 
people do, keep in mind that before the day ends, 2,000 
children will contract HIV/AIDS. That happens every single 
day--2,000 kids every, single day. So as we go through the 
steps of what we consider a normal day, just remember that at 
the end of this day, there will be 2,000 more children 
infected, and that goes on every day.
    So this is very, very important. I am particularly pleased 
to see that we have gotten the politics out of the way on this 
issue, that we are now talking about what we can do. And I 
think Senator Warner is absolutely right--this is a desperate 
health condition, but it also goes beyond that. It is a 
national security issue, and the fact that the world is 
beginning to really move on this is encouraging, and I am 
anxious to hear our witnesses.
    [The prepared statement of Senator Dodd follows:]

                   Prepared Statement of Senator Dodd

    Good morning, Mr. Chairman, thank you for convening this 
important hearing. I know of no greater threat to world health 
today than the threat presented by EV and AIDS. A simple review 
of the global numbers regarding the pervasiveness of AIDS is 
staggering, Mr. Chairman. It is my hope that today's hearing 
will lead us to strengthen our resolve to take on this 
horrendous disease that has already robbed us of 25 million 
lives since its first identification.
    Here in the United States, Mr. Chairman, an estimated 
850,000 to 950,000 individuals are living with the human 
immunodeficiency virus, or HIV, according to the Centers for 
Disease Control (CDC). An alarming one-quarter of these cases 
are currently undiagnosed. Each year, more than 40,000 
Americans will contract HIV, more than half under the age of 
25.
    An additional 338,000 Americans are living with AIDS. AIDS 
is now the fifth leading cause of death in the United States 
among people aged 25 to 44, and the leading cause of death for 
African-American men in this same age group. However, in the 
United States progress is being made. The estimated annual 
number of deaths due to AIDS in the United States fell 
approximately 70 percent from 1995 to 1999, from approximately 
51,000 deaths in 1995 to 15,000 in 2000.
    While this decrease is to be lauded, Mr. Chairman, similar 
decreases in other parts of the world have unfortunately not 
yet been realized. In fact, the spread of HIV and AIDS 
throughout the world has grown dramatically during the same 
period that the United States has decreased the toll extracted 
by both HIV and AIDS.
    Tragically, the Sub-Saharan region of Africa represents 
only 10 percent of the world's population, but more than 70 
percent of the world's HIV and AIDS-infected. More than 28 
million people in this region are infected with HIV. Last year 
alone more than 2.3 million Africans lost their lives to AIDS. 
Since the beginning of the AIDS epidemic, Mr. Chairman, an 
astonishing 19 million Africans have succumbed to this terrible 
disease. In most of the world, Mr. Chairman, the overall rate 
of HIV infection is 1.2 percent. Alarmingly, the same infection 
rate in Sub-Saharan Africa is 8.4 percent. In sixteen African 
nations, infection rates are above 10 percent and the nation of 
Botswana has reached an infection rate above one-third of its 
total population.
    I feel I would be remiss if I didn't mention the terrible 
toll that HIV and AIDS have taken on the children of Sub-
Saharan Africa. More than 12 million African children have been 
orphaned since the beginning of the AIDS epidemic. Today, more 
than 6.5 million AIDS orphans are living in Africa. These 
orphaned children face increased risk of malnutrition and 
greatly reduced access to adequate healthcare and educational 
opportunities. AIDS has literally robbed millions of African 
children of their parents, and too often, their futures.
    Equally tragic, Mr. Chairman, is the fact that countless 
numbers of children in the developing world will contract the 
virus that causes AIDS through contact with their own mothers. 
This year alone an estimated 500,000 children in the developing 
world will contract HIV from their mothers despite the fact 
that there exists already drug therapies that can virtually 
eliminate mother-to-child transmission of this devastating 
disease.
    This is not to say, however, that the solution to the 
global AIDS crisis rests solely with the availability of 
lifesaving pharmaceuticals. As I know we will hear from our 
witnesses this morning, just as importantly as access to 
medicines in our fight against AIDS is the development of 
adequate healthcare infrastructures in the developing world. We 
find time and again that without sufficient healthcare 
resources--such as adequately trained health professionals and 
access to suitable hospitals and clinics--we will continue to 
face an uphill battle that medicines alone will not win.
    Mr. Chairman, again, thank you for calling this important 
forum. I look forward to hearing from our witnesses this 
morning.
    The Chairman. Senator Sessions.

                 Opening Statement of Senator Sessions

    Senator Sessions. Thank you, Mr. Chairman, for calling this 
hearing.
    It is indeed time for us to act. We have done a lot, but 
much more needs to be done. I am not satisfied that any of us, 
certainly myself included, number one, have been as active as 
we should be in studying this disease.
    I talked to Dr. Frist several years ago, telling him that 
something needed to be done. He has traveled the world; he has 
gone out and talked to people and utilized his great scientific 
and medical expertise to help us focus on how to confront this 
problem.
    I certainly want to pledge my support to it. I believe that 
we have got to utilize the best science possible. We know, as 
Senator Dodd mentioned, that we can do more on children. That 
is something we know we can do. And there are other things that 
we know work with properly applied resources and scientific 
work and determination.
    I thank the chairman for holding this hearing and look 
forward with interest to hearing the testimony of the 
witnesses.
    The Chairman. Thank you very much.
    Just for the information of committee members, we have been 
notified that there will be three votes starting at noontime, 
so we have just over an hour. We will ask our witnesses if they 
can limit their remarks to about 7 minutes, and that will give 
each of us a chance to ask one or two questions.
    Sandy Thurman, we thank you so much for all that you have 
done and continue to do. We look forward to your comments.

 STATEMENT OF SANDRA L. THURMAN, PRESIDENT, INTERNATIONAL AIDS 
                     TRUST, WASHINGTON, DC

    Ms. Thurman. Thank you, Mr. Chairman, and other 
distinguished members.
    I am delighted to once again come before the committee that 
has played such a pivotal role in America's fight against AIDS. 
Since the early days of the epidemic, this committee has 
brought a spirit of commitment and bipartisanship to this 
vitally important fight.
    You have consistently demonstrated that AIDS can transcend 
politics and party affiliation and that by working together, we 
can make extraordinary progress. Your leadership in addressing 
AIDS here at home is unparalleled, and your willingness and 
commitment to fighting the pandemic around the globe is 
desperately needed and very, very much appreciated. I want to 
thank you all for your interest and your support.
    In 1982, when I cared for my first AIDS patient as a young 
hospice volunteer, I never dreamed in a million years that the 
kind of agonizing death that I witnessed would not have been 
stopped by the wonders of modern medicine.
    A year or so later, I again found myself alone at the 
bedside of a young African American man at Grady Memorial 
Hospital in Atlanta who had been abandoned by his family, lost 
his job and his apartment, and had almost been literally run 
out of town. He wound up in Atlanta living alone in an AIDS 
housing program.
    I had never seen a young man fail faster than that young 
man did. I will never forget the look of despair in his eyes as 
his life slipped away, and I held his bone-thin hand in mine. 
And while he was grateful for my presence, there was no way on 
God's green earth that I could replace what he had lost. As he 
called for his mother and I wiped his brow, I thought at that 
moment that I would die, too. I always believed that that young 
man did not really die of AIDS; he died of a broken heart that 
was a complication of ignorance and fear and discrimination. 
Surely, I thought at that moment in my life, we could be more 
compassionate, and surely this thing would come to an end soon.
    But I was wrong. The first year that I testified before 
this committee, I gave more than 50 eulogies for people who 
died of AIDS--a little more than one a week. The death toll was 
mounting, and for those of us who were working in AIDS at that 
time, it became painfully clear that there was no end in sight. 
Nearly a decade later, I found myself serving in the White 
House and visiting Africa to witness the epidemic there first-
hand--and there was that young man's face again, but it was 
multiplied by the thousands and indeed, by the millions. It was 
the first time in my professional career or my volunteer career 
that I understood what the word ``plague'' really meant.
    By any and every measure, AIDS is a plague of biblical 
proportion. I do not have to give you all the statistics. You 
know the statistics--every day, 8,000 people die of AIDS; every 
day, 14,000 people become infected; and, as Senator Dodd said, 
each and every day, 2,000 babies are born with HIV.
    But while the challenge before us is very, very great, it 
is not a cause for hopelessness and resignation, but for 
leadership and action. The good news is that we know what 
works. In two decades of living with AIDS, important lessons 
have been learned, and effective interventions have been 
developed and tested and evaluated over and over again.
    Over the past few years, I have had the opportunity to 
visit a dozen countries in Africa, to go to India, the 
Caribbean and see first-hand the extraordinary efforts that 
people on the ground are making with very, very limited 
resources.
    Teenagers are teaching their peers how to protect 
themselves from HIV using street theater. Nuns on bicycles in 
rural areas of Africa are delivering medicines to people who 
need them. Grandmothers are mobilizing to care for orphaned 
children in their communities. Village by village, nation by 
nation, we are seeing really impressive results.
    Broad-based prevention programs have stopped the epidemic 
in its tracks in Senegal, dramatically slowed the spread of the 
infection in Thailand, and slashed rates of new infections in 
Uganda by more than half, and we are now seeing the same kinds 
of results in Cambodia and Zambia.
    There is much more that needs to be done, and nowhere is 
the gap more glaring than in access to medical care and 
treatment for the millions of poor people living with AIDS, 
especially those in Africa.
    If 8,000 people a day are dying of a disease for which 
treatments to prolong life and reduce suffering are available, 
something is terribly, terribly wrong. But the reality is that 
only 5 percent of people with AIDS in Africa can even get the 
most basic care--and only a few thousand on the entire 
continent have access to antiretrovirals or triple-combination 
therapies. And currently, while the U.S. Government is 
providing some care and support, we are doing precious little 
to put pills in the mouths of people who really need them. As a 
global community, we can no longer sit back and watch this 
happen.
    I take issue with the argument that in the fight against 
AIDS, we have to choose between prevention and treatment. 
Survival is not an either/or proposition. Prevention and 
treatment are both essential and mutually-reinforcing 
strategies. We certainly learned that in the domestic epidemic 
in the 1980s.
    Unless treatment exists, there is little incentive for 
people to come and find out their HIV status. Yet it is through 
voluntary counseling and testing that some of the most 
effective behavior change actually occurs. Where treatment is 
offered, counseling and testing centers are literally swamped. 
I know that Senator Clinton has seen that in Uganda. And as 
people begin to live with AIDS, their presence in the home, in 
the workplace, in the church, and in the community begins to 
reduce the stigma and begins to bring AIDS out into the open 
where we can deal with it head-on.
    Providing care and treatment in Brazil has not only cut 
their AIDS death rate by 60 percent and saved the Government 
millions of dollars in hospital costs, but has helped to keep 
the number of new infections to about half what had originally 
been projected.
    More than a decade ago, in the name of our friend Ryan 
White, this committee fashioned legislation that has been a 
lifeline of hope and care for millions of American families 
living with HIV and AIDS. Today I urge this committee to lead 
the global community in finding ways to extend that kind of 
lifeline to families living with AIDS throughout the developing 
world. As the committee stated in that report: ``By dedicating 
this legislation to Ryan, the committee affirms its commitment 
to provide care, compassion, and understanding to people with 
AIDS everywhere. Ryan would have expected no less.'' That was 
12 years ago.
    We know the way. What we need now is the will and the 
wallet to get the job done. It is not a question at this point 
of whether we can or cannot--it is a question of whether we 
will or whether we will not.
    Mr. Chairman, Secretary Kofi Annan and UN AIDS have called 
on the global community to collectively provide $10 billion a 
year for HIV prevention and AIDS care programs in the 
developing world. If we are going to turn the tide in this 
epidemic, we have got to ratchet up our response so it begins 
to match the magnitude of the challenge. The world cannot keep 
trying to put out this raging fire with spoonsful of water. It 
just does not work.
    The Chairman. We will give you another few seconds to wind 
up.
    Ms. Thurman. Okay.
    In fiscal year 2002, the global community is spending 
approximately $2 billion, with about $800 million from the 
United States. That is why 250 organizations have asked the 
United States to commit the $2.5 billion that Senator Clinton 
talked about to the fight against AIDS.
    Mr. Chairman, I urge this committee to by a key player, to 
authorize at least $400 million at CDC to expand their 
essential prevention efforts, while directing new and 
significant attention to care and treatment. As CDC seeks to 
incorporate care and treatment in their ongoing prevention 
efforts, I believe the committee should direct HRSA to do the 
kind of training that they have learned so well in their 
experience with the Ryan White CARE Act.
    The Chairman. Just to be fair to all of our witnesses, we 
will ask you to conclude, and we will include your full 
statement in the record, and it was a very effective one.
    Ms. Thurman. Certainly. Thank you, Mr. Chairman.
    [The prepared statement of Ms. Thurman follows:]
                  Prepared Statement of Sandra Thurman
    Mr. Chairman, Dr. Frist, Senator Clinton and other distinguished 
members, I am delighted to once again come before a committee that has 
played such a pivotal role in shaping America's response to AIDS. Since 
the early days of the epidemic, this committee has brought compassion, 
commitment and a spirit of bipartisanship to this vitally important 
fight.
    You have consistently demonstrated that AIDS can transcend politics 
and party affiliation and that by working together we can make great 
strides. Your leadership in addressing AIDS here at home is 
unparalleled and your dedication to meeting the AIDS challenge around 
the world is very much appreciated and desperately needed.
    By any and every measure, AIDS is a plague of biblical proportion. 
To date, 25 million men, women, and children have already died, and 
each and every day the world loses another 8,000 lives to AIDS. And 
while 40 million people are now living with HIV, today and every day, 
14,000 more will become infected--one every 6 seconds. It is projected 
that by the decade's end, more than 44 million children will have been 
orphaned by AIDS--or nearly the same number of children as all those 
attending public school in the United States.
    In just a few short years, AIDS has wiped out decades of 
development gains in many African nations--where infant mortality is 
now doubling, child mortality is tripling, and life expectancy is 
plummeting by 20 years or more.
    AIDS is also having a dramatic impact on productivity, trade and 
investment--striking down workers in their prime, driving up the cost 
of doing business, and driving down GDP. Many businesses report having 
to hire at least two workers for every one skilled job, assuming that 
one will die from AIDS. Already, nurses and teachers are dying faster 
than they can be replaced.
    AIDS is beginning to chip away at security and stability--not just 
in nations hardest hit, but among neighbors, allies and all of us.
    And it is important to remember that the pandemic in Africa is just 
the tip of the iceberg, with the Caribbean already seriously affected 
and the fastest growing epidemics now found in India, China, and the 
Newly Independent States of the former Soviet Union.
    But while the challenge before us is great, it is not cause for 
hopelessness and resignation, but for leadership and action. The good 
news is, we know what works. In the two decades of living with AIDS, 
important lessons have been learned and effective interventions have 
been designed, implemented, and evaluated.
    Over the past few years I have had the opportunity to visit a dozen 
countries in Africa, India, and the Caribbean and to see first hand 
extraordinary efforts to stem the rising tide of new infections, to 
provide health care and hope to those who are sick, and to support 
children and families left behind--often with very limited resources.
    Teenagers are using street theatre to teach their peers how to 
protect themselves from HIV. Nuns on bicycles are delivering bactrim to 
people with AIDS in rural communities. Grandmothers are mobilizing to 
care for orphaned children. And village by village, country by country, 
in the face of seemingly insurmountable odds, we are seeing impressive 
results.
    Broad based prevention efforts have stopped the epidemic in its 
tracks in Senegal, dramatically slowed its spread in Thailand, and 
slashed rates of new infections by more than half in Uganda and now in 
some populations in Cambodia and Zambia.
    But there is much more that needs to be done and nowhere is this 
gap more glaring than in access to medical care and treatment for the 
millions of poor people living with AIDS, especially those in Africa. 
If 8,000 people a day are dying of a disease for which treatments to 
prolong life and reduce suffering are available, something is deadly 
wrong. But the reality is that only 5 percent of people with AIDS in 
Africa can get even the most basic care--and only 5,000 can now afford 
antiretrovirals. As a global community we can no longer be silent about 
the extent of this suffering.
    I am very troubled by the argument that in the fight against AIDS 
we must choose between prevention and treatment. Survival is not an 
either/or proposition. Prevention and treatment are both essential and 
mutually reinforcing strategies.
    Unless treatment exists, there is little incentive for people to 
learn their HIV status. Yet it is through voluntary counseling and 
testing that some of the most effective behavior change occurs. Where 
treatment is offered, counseling and testing centers are swamped, 
thereby accelerating prevention. And as people begin to live with AIDS 
their presence in the home, the workplace, the church, and the 
community reduces stigma and begins to bring AIDS out of the shadows 
where it can be fought head-on.
    Providing care and treatment in Brazil has not only cut their AIDS 
death rate by 60 percent, saving their government hundreds of millions 
of dollars in hospitalizations, but has helped to keep their number of 
new infections to less than half of what was projected.
    More than a decade ago, in the name of our friend Ryan White, this 
Committee fashioned legislation that has been a lifeline of hope and 
care for millions of American individuals and families living with HIV. 
Today, I urge this Committee to lead the global community in finding 
ways to extend that kind of lifeline to families living with AIDS 
throughout the developing world.
    The Ryan White CARE Act fostered the development of community-based 
systems of health care and support services across this country--
including many rural and resource-poor communities. In the early days, 
these care networks were run by family members, community outreach 
workers and volunteers, who didn't have triple combination therapies to 
offer, but could offer compassion, support, treatments for 
opportunistic infections, and palliative care. And these care systems 
began to change the course of the epidemic in this country while we 
moved to make newer and better therapies both available and affordable. 
Although not directly transferable, this is precisely what needs to 
happen in highly impacted countries worldwide.
    It is true that we will need procurement and distribution systems, 
more clinics, and more doctors, nurses, and community health workers, 
more training and capacity, but that can be done. Just think--no matter 
where in the world you are, you are no more than 2 minutes from a cold 
Coke. That means, where there's a will, there's a way. In the meantime, 
district hospitals, private sector clinics, faith-based, employer-
based, and community-based programs, and other settings provide safe 
and effective places to begin delivering care and treatment.
    We know the way. What we need now is the will and the wallet to get 
the job done. The question really isn't can we or can't we--but will we 
or won't we? I believe that the answer must emphatically be--we will--
and soon.
                        leadership and resources
    Mr. Chairman, what we desperately need is leadership and resources. 
UN Secretary General Kofi Annan and UNAIDS have called on the global 
community to collectively provide $10 billion a year for HIV prevention 
and AIDS treatment in the developing world. If we are going to turn the 
tide, we need to ratchet up our response so that it begins to match the 
magnitude of the challenge. The world can't keep trying to put out this 
raging fire with spoons full of water.
    In fiscal year 2002, the global community is spending approximately 
$2 billion--with slightly more than $800 million coming from the United 
States Government. As you can see, we are only one-fifth of the way 
toward our goal. In recent days, we have been reminded of the power of 
the United States to mobilize its allies against a common enemy. And no 
one is in a better position to build the coalition needed to win the 
war on AIDS.
    That's why nearly 250 organizations have called on the United 
States to move immediately toward its ``fair share'' of Kofi Annan's 
``war chest''--or $2.5 billion. To take this one step further--I would 
actually urge the United States to provide a ``leader's share'' of the 
$10 billion--or at least $3 billion--phased-in over the next few years.
    This is not a lot of money for something considered a global 
priority. For example, to prevent even a single casualty from the Y2K 
virus, the global community invested over $200 billion. Surely with 
tens of millions, perhaps hundreds of millions of lives at stake--the 
fight against AIDS deserves such an investment.
             legislation: hope, care and a can-do approach
    Mr. Chairman, in the context of USG leadership, there is a vitally 
important role for this committee and for the departments and agencies 
within your jurisdiction. As in our domestic response to AIDS, I urge 
this committee to be a key player in shaping our global AIDS action by 
providing significant contributions to the legislation currently being 
developed by the Foreign Relations Committee.
    I believe that essential components of HELP Committee legislation 
should include:
    Authorizing the CDC to expand essential HIV prevention efforts 
while focusing new attention on AIDS care and treatment. To that end, I 
would give serious consideration to a treatment set-aside which would 
include a Federal match of a private initiative to expand MTCT programs 
by providing the treatment needed to keep HIV+ parents alive to care 
for their children.
    As CDC incorporates care and treatment into their ongoing 
prevention efforts, HRSA should be increasingly involved in this 
process. HRSA is our health care delivery agency and its expertise 
gained from administering the Ryan White CARE Act is indispensable. 
HRSA also has a great deal to offer in the area of provider training 
and infrastructure development--vitally important to making these 
programs work in the developing world.
    In addition, I would strongly urge that the Committee authorize and 
push workplace-based HIV/AIDS programs through both the CDC and the 
Labor Department. With 5 to 40 percent of the labor force infected in 
many countries workplace prevention and treatment programs are 
essential and have proven effective.
    Finally, I urge this committee to work closely with the Foreign 
Relations Committee on a comprehensive and coordinated global AIDS 
strategy that allows the range of USG agencies to play to their 
strengths and collectively maximizes the USG impact.
                               conclusion
    In conclusion, the International AIDS Trust is extremely grateful 
that this issue is receiving the broad-based bipartisan support it 
deserves.
    There is much hope on the horizon, but that hope will only be 
realized if we join forces to save lives now. It will take a vibrant 
global public-private partnership to make this happen. Nevertheless, 
the pages of history are graced by times of great challenge when the 
global community mobilized and made a world of difference. As one of 
our board members, Archbishop Tutu, often says: ``If we wage this holy 
war together--we will win.''
    Let us seize the day.
    With the help of those in this room we are well on our way.
    Thank you very much.
    The Chairman. Our next witness is someone who is enormously 
gifted and talented as a singer and as a songwriter and who, a 
number of years ago, because of his own deep personal interest 
and concern and sense of compassion, developed a foundation. 
That foundation over the period of the past years has given 
more than $35 million to 55 different nations--an extraordinary 
act of generosity.
    This individual could be in many places around the world 
today, but he has chosen to be here because of his own very 
strong commitment, and he brings to this commitment both a 
wealth of information and caring.
    Sir Elton John, we are pleased to have you here and look 
forward to your testimony.

    STATEMENT OF SIR ELTON JOHN, CHAIRMAN, ELTON JOHN AIDS 
                 FOUNDATION, BEVERLY HILLS, CA

    Sir Elton John. Senator Kennedy, Mr. Chairman, thank you 
very much for inviting me. I feel very honored as a British man 
to be testifying to this committee, and I am very delighted to 
be here with all of these great colleagues who will be 
speaking.
    I have worn many hats in my career . . . some of which I 
have obviously regretted, but the hat of a policymaker is not 
one of them. I am not going to take up your time to tell you 
facts and numbers that you already know; instead, I will tell 
you how I feel.
    Twelve years ago last Monday, our friend Ryan White died of 
AIDS. We were completely devastated, his mother Jeanne most of 
all. Senator Kennedy, shortly after Ryan died, you called his 
mom, and you asked her to come to Washington help pass the Ryan 
White CARE Act.
    Ryan White was not the first friend of mine to die from 
AIDS, and he was not the last, but he taught me the most. 
People shut him out of school; they shot bullets into his home; 
they spread lies and slander about him. But Ryan did not hate 
them. He forgave them. He knew that they were uninformed and 
that they were afraid. He was troubled, though, when he gained 
so much sympathy for having AIDS, because he knew it was based 
on a distinction between people with AIDS who are innocent and 
people with AIDS who are not. He completely rejected that 
distinction.
    I remember just before Ryan died, sitting at his bedside in 
the intensive care unit with Jeanne, his mother. Ryan had 
fallen into a coma. When Jeanne saw the tears streaming down my 
face, she asked me ``What is wrong?'' and I said, ``With all of 
our money, we still cannot bring this boy back to life.''
    But Ryan not only moved me, he moved this committee, 
because you marshalled this country's first major response to 
AIDS--the Ryan White CARE Act. Thanks to your efforts, most 
Americans with HIV/AIDS now have access to care and treatment. 
This is a very moral and noble thing you have done. Democrats 
and Republicans came together, and together you gave suffering 
people hope and relief.
    Over the last 10 years, through the Elton AIDS Foundation, 
I have tried to do as much as I can with the money I have to 
make a difference. Since 1992, we have spent more than $35 
million in 55 countries, trying to eliminate prejudice against 
people with HIV and AIDS, trying to educate people about how to 
prevent AIDS, and trying to provide service and support to 
people living with AIDS and children orphaned by AIDS.
    Our first grant in Africa went to The AIDS Support 
Organization in Uganda, which is now a model of excellence for 
community-based programs across the continent. Our Foundation 
has increased access to HIV/STD education and prevention 
services for 50,000 women in slum areas of Sao Paolo, Brazil--a 
program so successful that the Brazilian government is putting 
up the money to double it.
    We are funding the Living With AIDS Project in Thailand, 
where home-based care, counseling and training encourages 
villages to support--not shun--friends, relatives, and 
neighbors living with AIDS. The first Elton John AIDS 
Foundation grant in Russia established a help line in St. 
Petersburg to provide information and counseling on HIV.
    We have also established an AIDS hospice in Soweto--the 
only project in Soweto providing inpatient care, day care, 
outpatient care, home care, and education and training. Among 
people with AIDS, the greatest fear is not of dying, but fear 
of dying alone. At our hospice, no one dies alone, and we are 
very proud of that.
    But, Mr. Chairman, our hospice in South Africa has eight 
beds, and the nation has more than 4 million people infected 
with HIV. We are doing everything we can with what we have, and 
we have comforted many people and saved many lives, but we have 
not done nearly enough.
    The people out on the front lines fighting this disease 
need reinforcements, and they need them now. That means more 
funding for education and prevention, more funding for 
voluntary testing and counseling, more funding for care of 
people with AIDS, and more funding for orphans, and it 
emphatically means more access to treatment.
    People with lives to lead and work to do and children to 
raise must not be left to die just because they are poor. This 
disease kills mothers and fathers, leaving orphans, and it 
kills orphans. It will not run its course except to destroy 
everything in its path.
    Mr. Chairman, 95 percent of the new infections come in poor 
countries. They do not have the resources to defeat it. They 
desperately need your help. No nation, corporation, foundation, 
or individual has the money that you have. No one even comes 
close. This is the Government of the richest nation in history, 
and I am here asking you for more money to stop the worst 
epidemic in history.
    If the United States says ``We have a moral obligation to 
act,'' then other major nations will follow. I am not a student 
of government, but I understand that there are two ends to 
Pennsylvania Avenue, and this end controls the money.
    Senator Dodd. Could you tell that to the other end? 
[Laughter.]
    Sir Elton John. The President cannot sign what you do not 
pass. If the world is going to make a significant, decisive 
intervention to change the course of this pandemic, it is going 
to have to start here, and it might as well start now.
    When Ryan White was asked by a reporter if he had a message 
for medical researchers working on AIDS, he said: ``Hurry up.'' 
We all need to hurry up. Every day we delay, we lose more 
lives, and we lose a little more of our own humanity.
    Mr. Chairman and members of the committee, we have one 
thing in common, you and I. We have all been on stage, and we 
have all heard the roars of the crowd. In my line of work, if 
you do not really want it to end, you can even keep it going 
for a few more encores, but soon enough, the lights go up, the 
crowd files out, and we all go home--and in that silence, we 
are left to ask ourselves whether what we do makes any 
difference at all.
    When our lives are done, won't we want it to be said that 
we saw millions of people suffering with disease, millions more 
at risk, millions more abandoned, a whole continent in danger 
of dying, and we refused to let it happen?
    Mr. Chairman and members of the committee, the United 
States Government is the biggest possible source of new funding 
for fighting AIDS. Forty million people are infected with HIV, 
8,000 people are dying every day. You have the power to end 
this epidemic. Please end it. Please end it.
    What American has done for its people has made America 
strong. What America has done for others has made America 
great. I pray that defeating AIDS will be one more great 
victory that you will win for the world.
    I may be reading from paper, but I really speak from the 
heart. My dream as a human being is to make sure that care and 
medicine are available to all human beings so that they can 
live with dignity and hope. You can make this dream a reality 
with your commitment to this terrible disease.
    Thank you.
    [The prepared statement of Sir Elton John follows:]
                  Prepared Statement of Sir Elton John
    Mr. Chairman, and members of the committee, I've worn many hats in 
my career . . . but the hat of a policymaker is not one of them. I will 
not take up your time to tell you facts and numbers you already know. 
Instead, I will tell you how I feel.
    Twelve years ago last Monday, our friend Ryan White died of AIDS. 
We were completely devastated--his mother, Jeanne, most of all. Senator 
Kennedy, shortly after Ryan died, you called his mom and you asked her 
to come to Washington to help pass the Ryan White Care Act. Initially, 
she said no. Ryan was the spokesperson. She couldn't do that. But she 
did.
    The month Ryan died, this committee passed the Ryan White Care Act 
that dramatically increased funding for care and treatment of people 
with AIDS. Mr. Chairman, the rest of the world looks at this 
legislation as a sign of what America can do for its people.
    We are here today to explore what America can do for the world.
    Ryan White was not the first friend of mine to die from AIDS, and 
he wasn't the last--but he taught me the most. People shut him out of 
school; they shot bullets into his home; they spread lies and slander 
about him. But Ryan didn't hate them. He forgave them. He knew they 
were uninformed and afraid. He was troubled though, when he gained so 
much sympathy for having AIDS--because he knew it was based on a 
distinction between people with AIDS who are innocent and people with 
AIDS who are not. He completely rejected that distinction.
    Over the last 10 years, through the Elton John AIDS Foundation, I 
have tried to do as much as I can, with the money I have, to make a 
difference. Since 1992, we have spent more than $30 million, in 55 
countries, trying to eliminate prejudice against people with HIV/AIDS, 
trying to educate people about how to prevent AIDS, and trying to 
provide service and support to people living with AIDS and children 
orphaned by AIDS.
    Our first grant in Africa went to The AIDS Support Organization in 
Uganda, which is now a model of excellence for community-based programs 
across the continent. I am delighted Noerine Kaleeba is here to tell 
you about it. Our Foundation has increased access to HIV/STD education 
and prevention services for 50,000 women in slum areas of Sao Paolo, 
Brazil--a program so successful the Brazilian government is putting up 
the money to double it. We are funding the Living With AIDS project in 
Thailand where home-based care, counseling and training encourage 
villages to support, not shun, friends, relatives and neighbors living 
with AIDS.
    We are reaching women in India with reliable information, 
affordable condoms and medical care, along with counseling about 
alternative job opportunities.
    We have also established an AIDS hospice in Soweto the only project 
in South Africa providing inpatient care, day care, outpatient care, 
home care and education and training. Among people with AIDS, the 
greatest fear is not fear of dying, but fear of dying alone. At our 
hospice, no one dies alone. We are very proud of that.
    But, Mr. Chairman, our hospice in South Africa has 8 beds, and the 
nation has more than 4 million people infected with HIV. We are doing 
everything we can with what we have, and we have comforted many people 
and saved many lives. But we have done nearly enough. The people out on 
the front lines fighting this disease need reinforcements, and they 
need them now.
    That means more funding for education and prevention; more funding 
for voluntary testing and counseling, more funding for care of people 
with AIDS, and more funding for orphans. And it emphatically means more 
access to treatment. People with lives to lead, and work to do, and 
children to raise must not be left to die just because they're poor.
    Senator Helm's op-ed calling for anti-retroviral therapy to help 
stop HIV-positive mothers from transmitting the virus to their babies 
is an important first step. But we need to take the second step. We 
need to treat the mother. If we don't treat her--who will take care of 
her baby? What if that baby comes to sit here in the Senate 10 years 
from now and says: ``Thank you for giving my mother the medicine that 
helped saved my life, but why couldn't you give her the medicine that 
would help save her life? Did you keep me alive just so I could bear 
the agony of burying my mother?''
    The drug companies are the only organizations in the world whose 
resources can rival those of rich governments in battling this disease. 
But, in my view, they have broken a public trust. They can't expect to 
keep pulling in profits, have their research subsidized, and then go 
missing in the midst of a world-wide health emergency. They can't keep 
telling us they're in the business of saving lives, if they always put 
business ahead of saving lives. We need them--and everyone--as 
partners.
    Mr. Chairman, it's late, but it is not too late. If we all step up 
now with a full commitment to fight AIDS, they can still have a heroic 
role in ending this epidemic. None have us have done all we could have 
done or should have done in this fight.
    Mr. Chairman, 95 percent of new infections come in poor countries. 
They do not have the resources to defeat it. They desperately need your 
help. No nation, corporation, foundation or individual has the money 
you have. No one even comes close. This is the Government of the 
richest Nation in history, and I'm here asking you for more money to 
stop the worst epidemic in history. I am no student of government, but 
I understand there are two ends to Pennsylvania Avenue, and this end 
controls the money. The President can't sign what you don't pass.
    If the world is going to make a significant, decisive intervention 
to change the course of this pandemic, it's going to have to start 
here. And it might as well start now. When Ryan White was asked by a 
reporter if he had a message for medical researchers working on AIDS, 
he said: ``Hurry up.'' We all need to hurry up. Every day we delay, we 
lose more lives, and we lose a little more of our own humanity.
    Mr. Chairman and members of the committee, we have one thing in 
common, you and I. We have all been on stage and heard the cheers of 
the crowd. In my line of work, if you really don't want it to end, you 
can even keep it going for a few more encores--but soon enough the 
lights go up, the crowd files out, and we all go home--and in that 
silence we're left to ask ourselves whether what we do makes a 
difference.
    When our lives are done, won't we want it to be said that we saw 
millions of people suffering with disease, millions more at risk, 
millions more abandoned, a whole continent in danger of dying, and we 
refused to let it happen. Mr. Chairman and members of the committee, 
the United States Government is the biggest possible source of new 
funding for fighting AIDS. Forty million people are infected with HIV. 
Eight thousand people are dying every day. You have the power to end 
this epidemic. Please end it.
    It's true that one nation cannot defeat AIDS in 200 nations. But 
200 nations cannot defeat AIDS without the help of one. This one. If 
the United States does little, other nations will see in that an excuse 
to do little. If the United States does a lot, other nations will do a 
lot, because they will see in your resolve a new hope of victory. When 
the United States fights, it wins.
    Mr. Chairman: what America has done for its people has made America 
strong. What America has done for others has made America great. I pray 
that defeating AIDS will be one more great victory.
    Thank you very much.
    The Chairman. Thank you very much for a very eloquent and 
compelling statement. It is certainly a challenge, not only to 
the members of our committee here, but to the institution and 
to the American people.
    We are very grateful to you for it.
    We will next hear from Dr. Peter Mugyenyi who, since 1992, 
has been executive director of the Joint Clinical Research 
Center in Kampala, Uganda and played a major role in the 
successful Uganda AIDS Control Program. Dr. Mugyenyi is 
currently chair of the Uganda Health Science Committee.
    Uganda has been one of the most successful countries in 
Africa in reducing HIV and AIDS, and this very special 
individual has done a very extraordinary job in seeing that 
that has been achieved.
    We welcome you here, Doctor, and we look forward to hearing 
from you. Thank you very much.

  STATEMENT OF PETER MUGYENYI, M.D., DIRECTOR, JOINT CLINICAL 
                RESEARCH CENTER, KAMPALA, UGANDA

    Dr. Mugyenyi. Thank you, Senator Kennedy. Thank you for 
inviting me here. I see some familiar faces. I thank Senator 
Frist and Senator Clinton.
    I testify as a physician who is working in AIDS and who has 
been involved for over 10 years, and every day of my life I see 
an AIDS patient as long as I am in my country, Uganda.
    I would like to give you some background to what is 
happening on our continent, because AIDS has devastated the 
continent of Africa. It has killed the youth in their prime and 
most productive age, and it has done this at the time when 
their families most need them.
    It has diminished skilled manpower in banks, in industries 
and institutions, and it has reversed hard-won advances that 
Africa was making. In fact, as has already been said, it is a 
significant political and destabilizing force on our continent.
    Just to give you a few examples, in Zambia, the country is 
losing teachers due to AIDS faster than they can train teachers 
to replace them. Every year, the capacity to train children in 
that country diminishes. A few years ago, it was estimated that 
South Africa would lose the economic advantage it had; growth 
would be down annually by 0.4 percent, GDP by 17 percent, and 
$20 million of the existing economy would be wiped out, let 
alone development itself.
    The situation has gotten worse since these estimates were 
made, and the situation is becoming grimmer. As you are aware, 
Africa is the home of AIDS. Over 70 percent of AIDS patients 
are found in Africa, and it is the leading cause of morbidity 
and mortality.
    I would like to take this opportunity to give you an 
example of my country, Uganda, which had the highest prevalence 
of AIDS in the world, but our government took strong measures 
through openness, public information, and the AIDS level has 
been reduced from a high of over 30 percent to the current rate 
of 6.2 percent.
    As good as this might look, it is still unacceptably high 
and appalling. Yet this is one of the most hopeful scenarios in 
Africa which needs to be emulated. But the situation elsewhere 
is much grimmer, and nowhere is it grimmer than in southern 
Africa itself.
    I would like to take you to a small country called 
Botswana, with a population of over one million, where in some 
sentinel sites, over 50 percent of women attending antenatal 
clinics are HIV-positive. Without treatment, 30 percent of 
these infected women will give birth to infected children.
    I would like to talk a little bit more to explain what this 
means. These infected children will be so sick that they will 
add to the strain of the medical sector. The mothers 
themselves--these 50 percent that I talked about--will die 
without treatment. When they die, they will leave orphans, not 
to mention the socioeconomic strain on the country and lessened 
capacity to educate these orphans.
    The health facilities in Africa are devastated. AIDS now is 
the biggest occupier of hospital beds in Africa. But AIDS is a 
secondary epidemic. These secondary epidemics of tuberculosis 
have now become a worldwide scourge and are killing most AIDS 
patients. There are other life-torturing diseases like 
cryptococcol meningitis, which causes excruciating headaches, 
tortures patients, and sends them into a coma before it kills 
them, inevitably, without treatment. That can be repeated for 
toxoplasmosis, that can be repeated for many other diseases, 
especially cytomegavirus, which makes them blind, they live for 
some time, they are totally helpless, and then they die. This 
is what we live with every day in Africa.
    Now, there is overwhelming evidence that prevention works. 
Uganda has demonstrated that prevention works. However, it is 
abundantly clear that prevention cannot work without treatment; 
it just works partway, but not well enough to make an impact on 
this very devastating epidemic.
    The main constraint we have in Africa is the high cost of 
the drugs. We are tackling, with our colleagues, especially 
from America, scientific issues that might help to deal with 
these scientific issues, which we now think are not a 
constraint to the use of antiretrovirals in Africa.
    My center, the Joint Clinical Research Center, has had a 
highly successful program of AIDS treatment using 
antiretroviral drugs. We did this without any help from any 
other country, but we could only do it in a very limited way. 
Our objective was to demonstrate that it works, and we have 
abundantly demonstrated that AIDS treatment works and works 
very well in Africa. Lives are saved in Africa when we use AIDS 
treatment.
    Now, the way forward. Africa needs the United States. 
Africa needs you to help us to come to grips with this problem.
    Currently, drugs are in very, very few places, yet the 
disease is in Africa. Drugs are where the diseases are not. The 
drugs should be in Africa. That is where the diseases are, and 
we need your help to get the drugs there.
    AIDS is a catastrophic tragedy, and arguably, surpasses all 
disasters of the centuries gone by. Yet this is very 
important--AIDS is actually one of those disasters that can be 
controlled. There are well-proven methods of controlling it, 
and there is treatment that is effective and available. We need 
help to make sure this treatment reaches us, and we look up to 
you to come to our aid, and when you do, we in Africa will play 
our role to make sure that this partnership is a winner, not 
only for Africa, but for the entire developing world, and 
indeed, the world itself.
    Thank you.
    [The prepared statement of Dr. Mugyenyi follows:]
               Prepared Statement of Peter Mugyenyi, M.D.
                                 impact
     HIV/AIDS has devastated the continent of Africa, killing the youth 
at their prime and most productive age, when their families and 
countries most need them, diminished skilled manpower in key industries 
and institutions and is reversing the hard worn advances in health, 
social-economic, and cultural development.
    In Zambia, the country is losing teachers due to AIDS faster than 
they can train replacements. Every year, the country's capacity to 
educate the children for a better future diminishes. A few years ago, 
economists estimated that AIDS in South Africa will slow down the 
economic growth by 0.4 percent annually, cut GDP by 17 percent, and 
wipe out $22 million of the existing economy by the year 2010. The 
situation has since gotten worse and estimates are being revised 
upwards. Africa is home to over 70 percent of the world's population of 
over 36 million people living with AIDS, and is the leading cause of 
morbidity and mortality.
                        the scope of the problem
    In early 1990s, Uganda had the highest prevalence of HIV/AIDS in 
the world, but the government implemented strong preventive measures 
through a policy of openness, public information, communication and 
education, and national and international collaboration through 
patternship of private and public sectors to bring down HIV/AIDS rate 
from the high level of over 30 percent in some antenatal sentinel sites 
to the current level of 6.2 percent. However, this rate remains 
unacceptably and appallingly high. Yet this is one of the most hopeful 
scenarios in Africa and an example to emulate. For the most of the 
continent the situation is much grimmer! Currently, the highest rates 
are in Southern Africa where the epidemic is causing unimaginable 
suffering, especially to the poorest sector of society. In some 
sentinel sites in Botswana, a shocking prevalence of over 50 percent of 
women attending antenatal clinics are HIV positive. Without treatment, 
over 30 percent of these infected women will give birth to infected 
children. These infected children will be so sick that they will add to 
the strain on the already over-stretched health sector. The mothers 
themselves will die, leaving a generation of orphans without parental 
guidance, not to mention the social and economic strain on the country 
and individuals concerned with lessened capacity for education and life 
achievements. The health facilities are already overwhelmed by the 
adult infected cases of AIDS who already occupy the vast majority of 
hospital beds with very serious opportunistic infections. Secondary 
epidemics of opportunistic infections have emerged and include 
Tuberculosis that kills most AIDS patients, Crypotoccocol Meningitis 
that tortures patients with excruciating headaches that progresses to 
mental confusion, coma and inevitable death if not treated, 
toxoplasmosis that causes terrible convulsions and eventual death, and 
Cytomegavirus infection that causes blindness and helplessness, and 
many other infections that could all be largely prevented, or at least 
ameliorated, by a program of treatment.
    The devastation and AIDS trend all over Sub-Saharan Africa is 
upward. The epidemic is totally out of control, the continent's 
economies increasingly unable to cope with the demand and scarce 
resources are diverted from other developmental programs in vain.
    There is overwhelming evidence that strong preventive measures 
implemented will have a big effect in control of the epidemic. However, 
it is abundantly clear that without treatment the AIDS epidemic would 
not be effectively controlled in the developing countries. The main 
constraint to treatment is the high cost of the AIDS drugs 
(antiretrovirals) which are beyond the economic means of most 
developing countries. The lack of adequate infrastructure and trained 
manpower is also a constraint that need to be addressed, but is not a 
major handicap to widespread use of Antiretroviral (ARV) drugs in 
Africa. The Joint Clinical Research Center (JCRC) in Uganda has 
implemented a highly successful program of AIDS treatment using ARV 
drugs just as they are used in the United States. The center has gone 
further to carry out operational research that would inform the way 
forward for countrywide good practice in ARV drugs use. Of particular 
importance are low cost, user friendly and sustainable laboratory 
diagnostic and monitoring tests. JCRC is now working with American 
scientists to identify simplified and cost effective ARV treatment 
regimen that may be adopted for wider use in Africa. Pilot projects in 
Uganda now also being implemented in some parts of Africa have 
demonstrated that AIDS treatment is feasible, desperately needed, and 
has the potential to impact on the epidemic control. Each country in 
Africa given the necessary resources can implement a successful 
preventive program, and start AIDS treatment, which can in a stepwise 
methodology be extendable to the communities. A nationwide referral 
system of specimens and patients may be one of the practical ways 
forward as infrastructure develops. An outline of such a program is 
outlined in the power point slides and can easily be adopted for 
implementation by all countries.
                              way forward
    It needs to be recognized that Africa, and indeed the entire 
developing world, is in urgent need of help to treat millions of people 
suffering the now mainly treatable AIDS. Currently, the drugs are not 
available where they are needed desperately, yet AIDS is the most 
catastrophic tragedy of humanity today, arguably surpassing all the 
disasters of the last century put together! Yet there are few disasters 
that can be so effectively controlled by well proven methods of 
prevention, care and treatment. Aid for AIDS should not be equated with 
the ``unsolvable'' vast problems of the developing world, but rather as 
part and parcel of the solution to such issues by investing in the 
human capacity of the people of Africa.
                            expected outcome
    With appropriate help AIDS can be controlled and moved from a 
devastating epidemic to a controllable sub-endemic disease. Many lives 
would be saved and the suffering would be minimized. It would make a 
saving in economic terms that would be injected into the economies to 
improve social services and relieve the strain on medical facilities. 
It would free the infrastructure to deal with the endemic tropical 
diseases that are also rampant, but only overshadowed by the 
devastation of AIDS. The governments would be under less pressure from 
their populations to concentrate on issues of family and development. 
The interventions are urgent because every year millions are added on.
                               conclusion
    There is great demand for AIDS drugs in developing countries. Huge 
numbers of desperate people staring death in the face know very well 
that life saving treatment exists. If they get hold of any drugs, 
whether fake, generic, bland, under dose or toxic, they will take their 
chance on it. This is a fertile ground for black-marketeering and for 
unqualified dealers to step in with disastrous long term implications. 
Governments and international donors must not let this situation 
develop further, and need to work together to avert this super-
catastrophe, by facilitating an effective program against AIDS.

    The Chairman. Thank you very much, Doctor. You have 
demonstrated what can be done and give us a great sense of 
hope, that if we give the support and resources, it can make a 
very important difference, and you have demonstrated that.
    Dr. Allan Rosenfield is currently dean of the Mailman's 
School of Public Health at Columbia University. He is currently 
chairman of the New York State Department of Health AIDS 
Advisory Council and chairman of AMFAR's Public Policy 
Committee. He has worked abroad, as well as domestically, on 
family planning and maternal and child health issues. He has 
pages of international awards, degrees, and achievements.
    We are very, very glad to have you here, Doctor. We are 
thankful for all of your good work in the past and look forward 
to your testimony.

  STATEMENT OF ALLAN ROSENFIELD, M.D.,DEAN, SCHOOL OF PUBLIC 
 HEALTH, COLUMBIA UNIVERSITY; DIRECTOR, MTCT-PLUS INITIATIVE, 
                          NEW YORK, NY

    Dr. Rosenfield. Thank you very much, Mr. Chairman and 
distinguished members of the committee. Thank you for inviting 
me to testify and, more importantly, thank you for holding this 
committee hearing.
    I thank my previous panelists, particularly Sir Elton John, 
for the eloquent presentations that have already been made.
    I am an obstetrician/gynecologist by training, so the 
impact on women and children is particularly touching and 
moving and important to me as a professional.
    I would like to use my time to discuss one of the issues 
that I think is of key importance and an approach to beginning 
to introduce more effectively treatment in poor countries.
    Mothers and children are suffering the heaviest toll from 
the AIDS epidemic. More than half the global toll of AIDS 
involves women and children. In one year, more than 1.5 million 
women die from AIDS while another 2.5 million become infected. 
According to UNAIDS estimates for 2001 alone, approximately 2.6 
million pregnant women had HIV infection, and more than half-a-
million transmitted the virus to their infants.
    To put this in perspective, as I think was mentioned 
earlier, more than 1,500 children become infected each day.
    Over the last few years, groundbreaking progress has been 
made in the prevention of maternal, mother-to-child 
transmission, called MTCT programs, using a well-established 
package of low-cost and effective practices including single 
doses of an antiretroviral drug, nevirapine, for both the 
mother and the baby.
    The Elizabeth Glaser Pediatric AIDS Foundation, UNICEF, 
Medicins Sans Frontiers, USAID, CDC, and many others are 
leading this global effort to expand these programs, and there 
are currently estimated to be more than 200 MTCT prevention 
sites in more than 20 countries, but we need much, much more.
    While MTCT programs to prevent mother-to-child transmission 
are a tremendous step forward, these programs do not--and I 
repeat, do not--provide treatment to the mothers themselves. 
The mothers simply deliver the drug to the babies.
    The tragedy is that the babies that we save through the 
MTCT programs are likely to be motherless by the time they can 
walk. Affording to studies in Africa, children whose mothers 
have died are three to four times more likely to die 
themselves--three to four times more likely to die--if they are 
orphaned.
    I believe we face a social and moral imperative to now add 
treatment of the mothers and their infected children. Survival 
of mothers will not only benefit the mothers, but will secure a 
brighter future for the children and will create optimism that 
can only further enhance prevention efforts.
    When the Elizabeth Glaser Foundation called their sites 
where the MTCT programs are currently underway, there was 
uniform and unanimous and enthusiastic support for expanding 
those programs to provide treatment for the mother, her 
children, and her partner.
    This is a unique moment in the history of the AIDS 
pandemic. We have an important opportunity to extend care and 
treatment to mothers and their families given the rapidly 
increasing possibility of providing treatment in poor areas, 
reduction in drug prices--and we need to work on that--the 
recognition that treatment is essential and complementary to 
effective prevention programs.
    The international foundation community has responded to 
this challenge by responding to a major new initiative called 
MTCT-Plus. This program will add care and treatment of HIV-
infected mothers and their families to existing MTCT prevention 
programs. This is a concrete example of how prevention and care 
can come together. The new initiative under my leadership and 
based on Columbia University's Mailman School of Public Health 
is currently supported by a partnership of nine foundations 
which are listed in the testimony, and is part of the 
foundation community's response to Kofi Annan's call to action 
on HIV/AIDS. These include Gates, Hewlett, Johnson, Kaiser, 
MacArthur, Packard, Rockefeller, Star, and United Nations 
foundations in a unique and unusual collaboration on the part 
of these foundations to pool their resources to try to work 
with the Global Fund in moving this forward.
    Our goal is to raise $100 million through the private 
sector, and we hope that we will be able to include Federal 
support for this program, perhaps matching that goal before we 
are finished.
    We are building a strong partnership between this program 
and the Global Fund for AIDS, Tuberculosis and Malaria; and in 
fact, as some of you know, we will be hosting the next Global 
Fund board meeting at Columbia University 10 days from today.
    What is the aim of the MTCT-Plus initiative? This 
initiative aims to demonstrate that HIV treatment can be 
delivered effectively and efficiently in resource-poor 
countries. It will serve to develop a model that can be 
replicated by others around the world. We will be working 
closely with the UN family of agencies, Federal agencies, and 
nongovernmental organizations on the design and implementation 
of MTCT-Plus to ensure effective coordination on a regional and 
global level.
    Ladies and gentlemen, committee members, for the pregnant 
woman with HIV infection today, the future is one of despair. 
She is offered one hope--the hope for a baby without HIV who 
will have to survive without her.
    In contrast, what we hope that MTCT-Plus will provide for 
this woman is a chance for her to survive, for her to be able 
to raise her own children, sustain her family, and contribute 
to her community.
    We urge you to allocate resources to join this private 
initiative as a public-private partnership, matching the 
private foundation funding, to expand this effort, and to make 
HIV care and treatment available to the women and families who 
desperately need our help.
    I think that Sir Elton put it so eloquently: This 
Government and this country has a unique opportunity to do 
more. Now is the time to do more. The pandemic is not slowing 
the way it should. We need help from this committee and from 
our Congress and from our country.
    We believe that with your leadership, resources, and the 
will to succeed, MTCT-Plus and all the other care initiative 
that will follow can save the lives of thousands now and create 
lasting hope for millions in the future.
    Again, thank you for allowing me to testify, and thank you 
for the work that you are doing.
    [The prepared statement of Dr. Rosenfield follows:]
              Prepared Statement of Allan Rosenfield, M.D.
    Mr. Chairman and distinguished members of the committee, thank you 
for inviting me to testify this morning. The global HIV/AIDS pandemic 
is clearly the most urgent health threat of our time, and your 
leadership and determination is very much appreciated.
    I am Dr. Allan Rosenfield, Dean of Columbia University's Mailman 
School of Public Health and DeLamar Professor of Public Health. I am an 
obstetrician/gynecologist by training and have dedicated my 
professional career to maternal and child health, both domestically and 
internationally. I currently chair the New York State Department of 
Health AIDS Advisory Council and the Public Policy Committee of the 
American Foundation for AIDS Research. Before joining the faculty at 
Columbia, I spent 7 years in the developing world--in Nigeria at the 
University of Lagos Teaching Hospital and in Thailand as Medical 
Advisor to the Ministry of Public Health.
    We have heard moving testimony this morning about the scope of the 
AIDS tragedy, particularly the devastating impact on children and 
families. I would like to use my time to discuss one of the solutions--
a new multi-foundation program to link prevention with care and 
treatment for HIV-infected women and their families in the poorest 
countries.
                         a program to build on
    Mothers and children are suffering the heaviest toll from the AIDS 
epidemic. More than 1.5 million women die each year from AIDS, while 
another 2.5 million become infected. According to UNAIDS estimates for 
2001 alone, more than 2.6 million pregnant women carried HIV, and more 
than half-a-million transmitted the virus to their infants. To put this 
in perspective, more than 1,500 children become infected each day.
    Over the last few years, groundbreaking progress has been made in 
the prevention of mother-to-child transmission (MTCT) of the virus 
using a well-established package of low-cost and effective practices, 
including single doses of the antiretroviral drug Nevirapine for the 
mother and baby. Nevirapine has been shown to cut transmission of the 
virus nearly in half and costs only $4 for the mother and child. In 
many cases, Nevirapine has been provided free of charge by the 
manufacturer. The Elizabeth Glaser Pediatric AIDS Foundation, UNICEF, 
Medicins Sans Frontieres, the CDC and others, are leading a global 
effort to expand MTCT programs, and there are now approximately 180 
MTCT sites in more than 20 countries.
    While programs to prevent mother-to-child transmission are a 
tremendous step forward, the tragedy is that the children we save are 
likely to be motherless by the time they can walk. These orphans face a 
life of poverty, malnutrition, and a host of social ills. According to 
studies in Africa, children whose mothers have died are three to four 
times more likely to die themselves. In the current MTCT programs, the 
mothers are offered no hope for their own survival, and without the 
prospect of treatment for themselves, they have less of an incentive to 
seek testing and participate in prevention programs in the first place. 
I believe we face a social and moral imperative to treat the mothers.
                      towards an mtct-plus program
    We have an important opportunity to extend care and treatment to 
mothers, given the rapidly increasing possibility of antiretroviral 
treatment in poor areas, drastic reductions in drug prices, and the 
recognition that treatment is essential to effective prevention. The 
critical need to go beyond prevention was clearly recognized by the UN 
Special Session on AIDS last summer in the Declaration of Commitment 
and by health advocates, international organizations and governments 
worldwide.
    The international foundation community is responding to this 
challenge by committing to a major new initiative called MTCT-Plus. 
MTCT-Plus will add care and treatment of HIV-infected mothers and 
families to existing MTCT prevention programs, in a concrete example of 
how prevention and care can come together. The new initiative, under my 
leadership and based at Columbia University's Mailman School of Public 
Health, is currently supported by a partnership of nine foundations \1\ 
and is part of the foundation community's response to Kofi Annan's Call 
to Action on HIV/AIDS. We are well on our way towards meeting our 
private foundation fundraising target of $100 million over 5 years.
---------------------------------------------------------------------------
    \1\ Bill and Melinda Gates, William and Flora Hewlett, Robert Wood 
Johnson, Henry J. Kaiser Family, John D. and Catherine T. MacArthur, 
David and Lucille Packard, Rockefeller, Starr, and the United Nations 
foundations.
---------------------------------------------------------------------------
    We are also building a strong partnership between MTCT-Plus and the 
Global Fund for AIDS, Tuberculosis and Malaria and will host the next 
Global Fund Board meeting at Columbia later this month. Our aim is to 
demonstrate to the Global Fund and others in the international health 
community that treatment can be delivered effectively in resource-poor 
countries. In addition, we are working closely with UNAIDS and WHO on 
the design and implementation of MTCT-Plus to ensure effective 
coordination on a regional and global level. Finally, we see tremendous 
opportunities for partnerships with bilateral assistance agencies and 
are already consulting closely with CDC, NIH, and USAID.
    The MTCT-Plus initiative will select existing MTCT prevention 
programs and add the ``Plus'' component, which includes HIV/AIDS care, 
treatment and support services for infected women and families. The 
package of services will include education, counseling, nutritional 
support, diagnostic testing, prophylaxis and treatment of selected 
opportunistic infections, like tuberculosis, and anti-retroviral 
therapy. Patient treatment will be guided by standardized clinical 
protocols that were developed by an international group of experts. The 
treatment guidelines will be flexible and will evolve as newer drugs 
and tests become available and as more is learned about HIV care in 
resource-poor settings.
    The MTCT-Plus care team will be multidisciplinary, and psychosocial 
support, patient education, and counseling will be available at each 
visit. Patients will be encouraged to choose from a menu of supportive 
services, tailored to local circumstances and the needs of affected 
families. While the focus of the program is on pregnant women and their 
children, sites will have the opportunity to design a family-centered 
program, enrolling husbands and other household members. MTCT-Plus will 
also support community outreach and education, and work to build 
linkages to local organizations and resources.
                            the first stage
    The first stage of the program will be to select 10-20 existing 
MTCT programs to serve as demonstration sites. To be eligible, these 
sites must be located in resource-poor areas where the HIV prevalence 
among women is greater than 5 percent; we anticipate that the majority 
will be in Sub-Saharan Africa. Sites must demonstrate their ability to 
provide MTCT prevention services, including voluntary testing and 
counseling, standard obstetric, gynecologic, maternal and pediatric 
care, and reproductive health and nutritional services. The sites must 
have the capability to expand their services to provide HIV care to 
infected women and their children. We are also requiring a 
demonstration of local community and government support.
    Selected sites will be given approximately $200,000 per year for 
personnel, training, laboratory costs, operational support, and minor 
infrastructure needs. In addition, we will provide technical 
assistance, any additional training required, oversight, and drugs 
including antiretroviral therapy. In some case, we will provide 
planning grants of up to $15,000 for the development of future 
applications.
    Earlier this year, we initiated a rigorous application process to 
select our first group of demonstration sites, and we have identified a 
panel of independent experts to review the applications. Application 
requirements include detailed descriptions of existing health services, 
proposed strategies for providing HIV/AIDS care and treatment within 
one year, and detailed budget proposals. More than 70 MTCT sites have 
already indicated their intention to apply, and we expect to announce 
the first sites by June and begin operation by the fall. We plan to 
select the second group of sites in late 2002.
    At current funding levels, however, we only expect to be able to 
enroll between 25,000 and 50,000 HIV-positive women, children, and 
family members over the lifetime of the program. A major financial 
commitment is needed to expand this program to the hundreds of 
thousands, if not millions, of affected families.
                         a model for the future
    The MTCT-Plus program provides a path towards bringing HIV care to 
women and their children. Delivering care and treatment to infected 
women and their families will prolong their survival--and their 
children's survival--and improve their well being. It can decrease the 
stigma associated with HIV and, with the hope offered by treatment, it 
can strengthen prevention programs. However, the foundation community 
cannot do this alone. Therefore, we urge the Congress to join us in a 
public-private partnership to expand this effort and begin making care 
and treatment available to the women and families who so desperately 
need our help. We believe that with strong leadership, sufficient 
resources, and the will to succeed, we can save the lives of thousands 
now--and create lasting hope for millions in the future. If we work 
together, we can make a difference.

    The Chairman. Thank you very much, Dr. Rosenfield.
    Senator Frist, would you like to introduce Ms. Dortzbach?
    Senator Frist. Yes. Thank you, Mr. Chairman.
    I have the pleasure of introducing our final witness today 
before we go to our discussion period. Ms. Deborah Dortzbach is 
currently the international director of HIV/AIDS programs with 
World Relief International in Nairobi, Kenya. Her extensive 
work in the HIV/AIDS field spans both the United States as well 
as Africa.
    Abroad, Ms. Dortzbach has provided direct medical relief as 
a nurse in Ethiopia, Eritrea, and Kenya. She has also been 
program director of health training programs and HIV/AIDS 
support programs with Mission to the World and MAP 
International.
    Ms. Dortzbach, thank you for being with us this morning.

STATEMENT OF DEBORAH A. DORTZBACH, INTERNATIONAL DIRECTOR, HIV/
    AIDS PROGRAM, WORLD RELIEF INTERNATIONAL, BALTIMORE, MD

    Ms. Dortzbach. Thank you.
    This is not an easy position to be in, last on this panel. 
But I do look forward to a thunderous encore to this issue that 
we are addressing today, together. And we will applaud you, our 
Senators--the world will applaud you--for your energy and 
enthusiasm and action to what we are presenting to you today.
    I have brought someone with me, but you will not see her. 
Please do listen to what she has to say.

    [Remarks of Elizabeth via audiotape:]
         My name is Elizabeth, and I am 11 years old. I live in 
        Kenya with my mother and two brothers. My father died 
        of AIDS 2 years ago. My mom has AIDS. After my father 
        died, relatives came and took all of our family 
        property. Now we struggle to get money for school fees. 
        I do not know what will happen in the future. If my 
        father were alive, I would be the happiest girl in the 
        whole world.

    Ms. Dortzbach. Elizabeth's story is not over. She will 
still face the death of her mother, the stigma which Sir Elton 
John referred to of her neighbors and her friends, and she will 
probably not finish school.
    The question we have is what can we do to make an ending 
that is different for Elizabeth and the millions like her.
    Africa has been my home for 22 years. As an American, I was 
extremely vulnerable one day when a band of rebels entered the 
hospital where I was working and took me hostage for 26 days.
    You know the end of my story--I am here with you today, and 
I am grateful that I was released and could return to Africa. 
There, I was hopeful in the 1970s and the 1980s, when we helped 
children survive to the age of 5. But in the 1990s, we buried 
them as young people.
    I am with World Relief, located right here in Baltimore at 
our headquarters. We work for about 45 different denominations 
and all different religious and faith-based groups throughout 
the world, in 24 countries, and we have been around since 1944.
    I would like to suggest a few opportunities that the band 
of nongovernmental organizations, many of whom are here today, 
can contribute to the challenge before us in this crisis.
    We call our HIV/AIDS program Mobilizing for Life, and we 
work through the family, the basic unit that we are given, to 
nurture and to care and support and provide for our orphans, 
extended as well as nuclear.
    In Mozambique, there is a group of 50 churches that have 
shed their different denominational perspectives and are coming 
together to care, in homes, for 352 orphans.
    The faith community is here to stay, beyond our funding 
cycles and after we leave our rusty four-by-fours. In Kenya, a 
group called Faraja, which means ``comfort'' in Swahili, is a 
simple group of men and women. Their only badge is this little 
piece of metal, but they are recognized in their community as 
people who bring comfort. It does not cost anything, but what 
they give us is priceless.
    This did cost something. This small manual, ``Hope at 
Home,'' is simple enough that even children can understand it 
and use it, because like it or not, they are the primary 
caregivers of their dying parents.
    I am proud to say that my Government, through USAID, funded 
this project, and we need more. Financial strengthening is 
another area of interest for World Relief. We have credit and 
savings in small loans with more than 73,000 clients worldwide 
in 10 different countries. Ninety percent of them are women. 
They do not default on their loans; they have a loan loss rate 
of less than 2 percent. But what it does give them is a 
stronger economic base and the financial strength so that they 
have better options and choices to prevent AIDS from entering 
their families and affecting their children.
    We cannot do this alone--none of us can. That is why we are 
here today. That is why we plead with you. We need people; we 
need training; we need networking; we need each other. Only by 
working together can we make a difference in this crisis.
    I am grateful that our organization has partnered with 
many, including Freedom from Hunger, based in California, and 
their phenomenal track record in microenterprise development in 
health education. Together, we have developed a curriculum that 
is used worldwide in helping community banks understand more 
about HIV/AIDS.
    But it is not just organizations. It is individuals who 
make the difference. In New York City, I worked with Anna, 
Jerome, Maribel, Raquel, all of them nurses who wanted to get 
involved and even come to Kenya and help out in some small way.
    There are children in Fredericksburg, VA who are helping to 
make small bed pads for people in Africa who have problems with 
bedsores.
    I was powerless while being held hostage by terrorists, 
taken because I was an American. But today, I am strengthened 
because I am an American. And I know that my country has power, 
influence, and money to change the course of millions of 
Elizabeths, their mothers, their dads, their families. We 
cannot bring back Elizabeth's dad, but we can raise her and 
love her and help her live until she reaches her 70s.
    Join us in the NGO grassroots assault on the terror and 
tragedy of AIDS.
    [The prepared statement of Ms. Dortzbach follows:]
               Prepared Statement of Deborah A. Dortzbach
    Mr. Chairman and members of the committee, thank you very much for 
the opportunity to appear before this subcommittee. I am Debbie 
Dortzbach, International Director for HIV/AIDS for World Relief located 
in Baltimore, Maryland. We are a worldwide organization committed to 
alleviating suffering in the developing world.
    I am here today to represent the non-government agencies and to 
address how we can contribute to curbing HIV/AIDS and caring for those 
affected.
                          i. elizabeth's story
    You haven't met her, but you know her.
    She is one among millions you have talked about in these rooms. It 
is our time now to listen to her.

         My name is Elizabeth, and I am 11 years old. I live in Kenya 
        with my mother and two brothers. My father died of AIDS 2 years 
        ago. My mother also has AIDS.
         When my father died, my uncles came and took all our property. 
        Now it is difficult to get money for school fees.
         If my father were alive, I would be the happiest girl in the 
        whole world.

    Elizabeth's story is not over. She will face the death of her 
mother, confusion over what to tell people who scorn AIDS as a curse 
from generation to generation, the reality of stigma and rejection, the 
loss of household income, the threat of having to stop school, and the 
reality of not having an evening meal or the next morning's breakfast.
    By 2010 we will have 41.6 million double orphans, those who have 
lost both mother and father (Children on the Brink, USAID Report by 
Susan Hunter and John Williamson, 2000).
    As I think of Elizabeth, I am burdened by the question, ``What role 
can we have in giving Elizabeth's story an ending of hope?''
    Africa is also my home, now for more than 22 years. I am an 
American, and because I am, I was targeted in a 1974 hostage raid on a 
church hospital in northern Ethiopia, now Eritrea. After 26 days I was 
released to my husband and 4 months later gave birth to our son.
    We returned to Africa, invited to join the vigorous efforts of 
hundreds of thousands of ambitious and determined Africans in advancing 
their cultures and countries and participating in their health and 
development initiatives. I expected years later to leave Africa a 
changed place: with healthier children, more educated families, men and 
women honoring each other, and families strengthened with a brighter 
economic future.
    It is more likely that in next 10 years before we retire that many 
markets and streets will be flooded with orphans, families impoverished 
for generations, schools barren of teachers, and roads impassable for 
lack of skilled workers and money to repair them.
    In the 1970s and 1980s, we helped children survive to the age of 5. 
In the 1990s, we buried them as young adults.
    As a former hostage, I often wonder why God spared me. Why did I 
come home? There were two of us taken and Anna was shot, by our 
captors, in my presence.
    Today, I still ask that question, but I know just a bit more of the 
answer.
    We have a job to do.
              ii. the challenges and contributions of ngos
    Today, I am addressing you as a member of the family of World 
Relief, a Christian NGO representing more than 49 different 
denominations in the United States and working in over 24 countries 
since 1944.
    Our challenge is to apply foundations of sound knowledge about what 
works in AIDS, cultural strengths, spiritual commitments, and decades 
of public health and behavior change experience.
    We know these foundations build success. We need focus to 
strengthen them. In World Relief we call our HIV/AIDS program, 
``Mobilizing for Life,'' and our focus can be summarized around three 
themes: the family, the faith community, and financial strengthening.
A. The Family
    The basic social foundation is the family. To a very large extent, 
what happens within the family determines the global course of this 
epidemic. Strengthening communication, education, and cross-
generational dialog within the family is one of the goals of a USAID-
funded project known as Amkeni, in which we are partners in Kenya.
    The project works through churches and other community groups to 
foster understanding and equip families to reflect on behavior and 
promote relational and sexual health. Choose Life: Helping Youth Make 
Wise Choices is one tool with many lives. Originally developed through 
a USAID Rwanda project, (USAID/Rwanda/HARR Award No. 623-A-00-99-00071-
00), the manual is adapted and currently in use in training in Kenya.
    The family is also the primary institution for care of orphans and 
other vulnerable family members such as the elderly. Though taxed 
beyond coping ability in some cases, the majority of extended family 
members and the community surrounding them are the best homes for 
children whose parents have died. Every community institution can 
support the family, keeping children at home where they belong. 
Kubatsirana, a Mozambiquan organization of faith communities in Chimoio 
representing over 50 churches is an example of communities working 
together to assist over 352 orphans. Every orphan is known, every 
village elder oversees their welfare, every church takes on the 
responsibility of visiting and supervising care regularly, and every 
school and many businesses in the community assist in meeting basic 
needs.
B. The Faith Community
    In nearly every community in Africa people meet to express their 
faith. Faith communities are institutions here to stay, beyond our 
funding cycles and rusted 4x4s. What we build today on the foundation 
of faith is cost-effective, integrated into life and relationships, and 
spans generations.
    Faraja, meaning comfort in Kiswahili, is a community of people of 
faith from many backgrounds drawn together out of concern for caring 
for people with AIDS at home in an urban poor community in Nairobi. 
Members of Faraja dedicate themselves to weekly learning sessions on 
how to train family members to care for their HIV-positive members. The 
training occupies no line-item in a budget and does not take place in 
an expensive hotel, but sitting on wooden benches in a tin-roofed 
church buried in the sprawling slums. The learners bring their passion 
and time and commit to working in teams, regularly visiting all sick 
living near them. What they learn costs nothing to do and can be 
universally applied and life-changing: the importance of touch and 
embrace, acceptance and inclusion of persons living with HIV/AIDS 
(PLHA), the need for PLHAs to stay active in the family and society, 
the control of TB, preparation for death and the care of orphans left 
behind. Faraja members use a simple home care manual, ``Hope at Home.'' 
It has photographs and simple, short sentences so even children--who 
are often the primary caretakers of their parents--can understand and 
safely assist. Local government clinics and an area hospital provide 
HIV testing for family members, clinical support and backup for 
critically ill patients. Faraja caregiver trainers are recognized by 
the red badge they wear, ``Wahumu wa Faraja''--people bringing comfort.
    In Rwanda, faith communities send their leaders to workshops to 
apply community advocacy roles, learn principles of counseling in 
trauma healing, destigmatize AIDS and the misbelief that AIDS is a 
curse from God, learn the facts about HIV/AIDS, and use training tools 
to help youth make wise choices about their sexuality. As a result, 
more than 160 support groups of persons living with AIDS meet weekly in 
churches for support. Churches are developing their own integrated 
programs for AIDS interventions in care and prevention, including 
counseling, training, care, and food distribution.
    In Malawi, churches band together in committees to determine how to 
help the families affected by AIDS living around them. They work 
community gardens where volunteers cultivate, fertilize, plant, water, 
weed, and harvest food for orphans.
    The church is an advocate for those too weak to speak. In 
Mozambique, church leaders take village chiefs around their communities 
to identify orphaned children. More than 352 children in Chimoio are 
guaranteed the right to free primary education and businessmen and 
women contribute food and other necessary household items to the 
orphans.
C. Financial Strengthening
    World Relief enables individuals and families affected by HIV/AIDS 
to live with dignity by addressing the economic burden of HIV/AIDS 
through micro-enterprise development programs. Economic development 
opportunities give poor women, who are among the most vulnerable, 
better means to make healthy choices about sexuality.
    Credit and savings enable families to appropriately address the 
medical needs of their members with AIDS, continue to nurture children 
left behind by the death of their parents, and remain engaged with 
their communities. HIV/AIDS-affected families who participate in micro-
enterprise programs continue to earn income, maintain social support, 
and make wise decisions about treatment options. Micro-enterprise 
activities also help prevent new infections. Women, who are empowered 
socially and economically through their micro-enterprises, gain more 
control of their lives.
    World Relief assists in the administration and supervision of 
microfinance institutions in 10 countries including Rwanda, Mozambique, 
Burkina Faso, Haiti, and Cambodia, with a loan portfolio of 5.8 USD. 
These institutions serve 73,000 clients, nearly 90 percent of whom are 
women, with a loan loss rate of less than 2 percent. Most of these 
women move on to larger loan cycles and savings schemes.
    In partnership with another non-government agency, Freedom from 
Hunger, we developed an interactive prevention and care curriculum, 
``Facing HIV/AIDS Together,'' being used in communities where clients 
meet regularly as a group to repay their loans (Publication made 
possible through the G/PHN/HN Grant Award #HNR-A-00-07-00007-00).
    In addition to providing basic education on cause and prevention, 
the curriculum encourages communication within families, mobilizes 
these groups for community action and helps break down stigma.
    Rose Mukamguguje, an HIV-positive Rwandan widow, struggled to feed 
and educate her children after her husband died. She was forced to pull 
her six children out of school because she couldn't afford the fees and 
was concerned about what would happen to them when she died. Before she 
received a loan to start her own business, Rose was engaged in the 
back-breaking work of hauling construction materials. In her words: ``I 
used to get temporary jobs fetching water or bricks at a construction 
site, but this was very difficult for me. The next morning I would be 
broken. I would be very weak and stay in bed. I got sick more often 
during this time.''
    But through this bleak reality glows light--the light of people of 
faith practicing what they believe in nearly every community in 
Africa--far from medical outposts, medical professionals, corner 
pharmacies, means of transportation other than footing, and 
communication.
                 iii. implementing prevention and care
A. People
    In America, we think of hospitals, doctors, and medications when we 
think of treating AIDS. In reality, we will never have enough 
accessible hospitals and doctors to meet the demand, and we need to be 
realistic about the availability of medications over the long haul in 
most rural communities and urban poor centers where daily earnings are 
less than the cheapest American hamburger.
    But we have people living in community. They are neighbors, 
teachers, nurses, pastors, and youth. They are the greatest community 
resource, not yet fully marshaled or supported.
    In Malawi, youth groups meet the challenge of helping families with 
AIDS by hauling jerry cans of water, repairing roofs, tilling gardens. 
They learn not only how to give community service, but come face to 
face with the reality of people dying with AIDS--a powerful incentive 
for delaying sexual activity.
    Through working within community structures, equipping, and 
continued support and encouragement we can meet the most basic needs 
for not some, but most people living and dying with AIDS and their 
millions of orphans.
    World Relief's orphan initiative begins with families, communities, 
and churches. Rather than a project, it is described as a ``movement'' 
known as ``Every Church, Every Orphan'' seeking to marshal support from 
every church in every community where there is one to take a census of 
every orphan in a perimeter around the church and provide regular 
supervision and support to orphans without families. The support starts 
before parents die and includes the development of memory books for 
parents to leave with their children, the planning of the care of 
orphans with extended family members, and the handing over of family 
businesses or membership in community banks.
    As a global community we must continue striving for available 
medications for treating AIDS, a universal prevention vaccine, and the 
interruption of maternal-to-child transmission. In addition to these 
medical interventions we must continue to struggle with deep root 
issues engulfing AIDS: early experimentation of sex among youth, adult 
sexual exploitation of youth, the vulnerability and powerlessness of 
many women, stigma, the lack of communication, commitment, respect, and 
honor in many marriages, economic and social destruction of families.
B. Training
    The tenets of training that transform are interactive involvement 
of the trainees, training that is held in the local environment, 
utilizing people's own readily available resources, training that 
builds on beliefs and provides reflection and guidance toward 
understanding truth when beliefs may contradict fact, and opportunity 
to act on the lessons learned.
    A challenge for NGOs has been to work with some faith-based groups 
where AIDS is considered a curse or the condom an evil object. When 
time and effort are taken to meet people on their own terms, using 
their own community, religious, or family structures, very traditional 
beliefs can be discussed. Building trust is critical to deciphering 
error in erroneous traditional beliefs about AIDS. Some religious 
communities in Kenya began to change some of their views and reduce 
stigma associated with AIDS through training and role models of key 
leaders. A lesson learned in a large USAID/AIDSCAP project in 1996 
demonstrated that change does occur among church leaders when sources 
of information can be trusted by church leaders, and they are given 
opportunity to dialog together.
    Training is effective when a variety of training tools are 
utilized. We have developed mass media radio spots in Rwanda, an 
interactive video in Malawi and Kenya, low literacy flip charts in 
Malawi, and curricula for youth and micro-enterprise development. All 
of these tools have had no ``shelf life'' and are in demand for 
reprinting, adaptation and distribution throughout Africa, and some 
countries in Latin America and Asia.
C. Networking and Collaborating
    None of us have the answers or the abilities to fully apply the 
answers we are discovering. We need each other.
    We actively support cross-sectoral collaboration and have attended 
the monthly meetings of the Private Voluntary Organizations Steering 
Committee on HIV/AIDS at USAID. We have facilitated getting HIV/AIDS on 
the agenda of the practitioner networks to which we belong: the Small 
Enterprise Education and Promotion (SEEP) Network and the CORE network 
whose focus is maternal and child health. Both of these networks now 
have working groups to promote the HIV/AIDS agenda and to explore how 
they can work together more efficiently and effectively.
    We also encourage this dialogue at the national level. For example, 
in Cambodia and the Philippines, World Relief has sponsored forums that 
bring the economic and health sectors together to discuss cross-
sectoral collaboration for HIV/AIDS. In Rwanda, we helped establish the 
Rwanda Microfinance Forum, a group well aware of the economic issues of 
HIV/AIDS, addressing economic coping strategies and promoting AIDS 
education to member organizations. We have worked hard to integrate an 
appropriate response to HIV/AIDS into our microenterprise development, 
maternal-child health and youth programs to realize greater impact and 
more efficient use of our resources.
    World Relief helped form a network of local and international NGOs 
in Malawi that were not only HIV/AIDS specific, but multi-sectoral. The 
network meets quarterly to inform each other of events, materials 
developed and lessons learned.
    In Kenya, our staff was on the organizing committee of the Kenya 
AIDS NGO Consortium (KANCO) with present membership over 100 local and 
international NGOs working in Kenya.
    Information is vital to share. For that purpose we attend and 
present at international forums including the global International AIDS 
Conferences, the International Conference on AIDS and STDs in Africa, 
the Microcredit Summits in Asia and Africa, and the Prescription for 
Hope Conference in Washington, DC.
    Collaboration begins at home. Nurses from New York City are keen to 
not only continue learning about home care initiatives in Africa, but 
also want to volunteer themselves to help. In this meeting in Manhattan 
just weeks after September 11 these nurses drank in all they could 
learn about AIDS in Africa and determined to support the efforts of 
their nurse colleagues in Kenya. In other areas, children in Virginia 
are sewing simple bed pads to help control skin problems resulting from 
diarrhea.
                             iv. conclusion
    In 1974, I was powerless while being held hostage by terrorists, 
taken because I was an American. Today, I am strengthened because I am 
an American who, together with you and those you represent, have power, 
influence and money to change the course of millions of Elizabeths and 
families with AIDS whose deaths in the first decade of the 21st century 
alone will rival the number that died in all the wars of the 20th 
century. [Remarks prepared for delivery by Vice President Al Gore at 
the UN Security Council Session on AIDS in Africa, January 10, 2000].
    Join the NGO community in their grassroots assault on the terror of 
AIDS. Embrace the responsibility and challenge before us as Americans.

    The Chairman. Thank you very, very much.
    I know that Sir Elton John has to leave in just a few 
minutes, so I will ask my colleagues if they have particular 
questions for you, and then we will excuse you if that is all 
right.
    I would just like to ask you one question for a brief 
response. You have been enormously generous with your time.
    You talked about the importance of resources, and that is 
obviously one of the major factors that have been reviewed by 
yourself, Sandy Thurman, and others. What other kind of 
leadership do you think the United States could provide? You 
have had a chance, obviously, to talk with people in all parts 
of the world. Resources are a major factor, and they may not be 
the answer to everything, but it is a clear indication of a 
nation's priorities, and we cannot minimize that. But what else 
would you say that you would expect from the United States in 
terms of leadership?
    Sir Elton John. I think the fact that this committee would 
even consider granting money and extra money to much-needed 
projects throughout the African continent--all eyes seem to be 
on America. This is a great country. You believe it is a great 
country, and we believe it is a great country. I think that by 
showing the compassion--the money is one thing, but the 
humanitarianism and compassion is another. And America always 
has been a compassionate Nation.
    And I think just the publicity that one gets from things 
like today shows that America cares. All the resources in the 
world does not take away from the fact that if someone cares, 
and someone wants things to happen, that is so important as 
well.
    I was very moved by the last speaker, and she was very 
proud to be an American serving in Africa. That is an 
advertisement in itself for this country.
    I just think that when the reports are made today, just the 
fact that you are sitting down today, and you care so much as a 
committee is an incredibly important thing. Compassion these 
days seems to be in short supply following the events of the 
last year. There is a lot of anger and hatred in this world, 
and I think compassion is the strongest form to combat that, 
and you show that as a committee.
    Thank you.
    The Chairman. Thank you.
    Senator Clinton.
    Senator Clinton. Thank you so much.
    Sir Elton, I want to ask you specifically about what you 
have done in Brazil, because there is often debate that we 
cannot--it is what we call a ``chicken and egg'' problem--we 
cannot provide the care and treatment because we do not have 
the infrastructure, but we do not have the infrastructure so we 
cannot provide the care and the treatment. You were really in 
on the ground floor with your foundation in Brazil, and as I 
understand it, you created a program even where the country was 
not yet ready to face up to some of the implications of the 
HIV/AIDS pandemic, and by demonstrating that it worked, you got 
the government to respond.
    Could you describe that?
    Sir Elton John. Well, it is a bit like matching grants, 
when you fund a grant and get it matched by people. The 
initiative in Sao Paolo was an extreme success, but it was not 
done with the government's help. It was done entirely from our 
organization and with the help of other people. And when the 
government saw that it was a great success, they helped as 
well. You set the example. You cannot sit back and wait for 
things to happen. You have got to go in there. We always 
investigate everything we do. We send a team out to make sure 
that our money is being put to the best possible use, and we 
thought this was an incredible opportunity to do something in 
Sao Paolo, and it proved to be a huge success. By taking that 
initiative--you have to take the initiative with this disease; 
you cannot wait for people to say, ``Oh, no.'' Look at the 
epidemic that happened in this country in the early 1980s. The 
government really did not take any initiative at all, and it 
was up to people to demonstrate their anger and to say, 
``Listen, we need action.''
    I think you have to take the initiative sometimes, and then 
you get people to thinking, ``Oh, that works really well. We 
will help.''
    We are a very small organization, but we have funded over 
53 countries, and we do make sure that in everything we do, the 
money is really well-spent, and if the success of the venture 
is apparent, people always take notice. That is all that we can 
do, really.
    Senator Clinton. Thank you.
    The Chairman. Are there any other questions for Sir Elton?
    Senator Warner.
    Senator Warner. Thank you, Mr. Chairman.
    Sir Elton, our job, those of us who take an active role in 
this and have and will continue to do so, is to convince a lot 
of colleagues. In just a few simple, understandable words--you 
are approaching a fellow colleague as if you were a Senator--
how would you describe the race in terms of the rapid 
proliferation and expansion of HIV/AIDS, both here domestically 
in our country, and worldwide, but particularly worldwide; and 
how fast is the catch-up procedure of medicine and health? Is 
it not a widening gap between the efforts thus far to attenuate 
and cure and the race of the disease in terms of its 
proliferation?
    Sir Elton John. Well, we do have a lot of catching up to 
do. I would approach someone--if one could precis the doctors' 
statements and Ms. Dortzbach's speech, which was the most 
moving testimony you could have--I think you have to approach 
someone who is skeptical by consistently clubbing them over the 
head. I mean, we have been talking about this disease for so 
long, and it has been well-publicized. This epidemic, this 
pandemic, has had a lot of publicity. But as someone said at 
the beginning, people still do not seem to get it; they do not 
seem to get the implications healthwise, economically, and 
socially, the impact that this is going to have.
    You just have to keep on and on and on at these people who 
are the doubting Thomases of this world. You have already 
converted Mr. Helms, which is an incredible achievement, and 
who would have thought? [Laughter.]
    So I defy anyone to be uncompassionate in regard to this 
disease.
    Senator Warner. Again, am I correct in the assumption that 
the proliferation of this disease is outpacing the efforts to 
try, scientifically and medically, to care for it?
    Sir Elton John. At the moment, yes. And unless we do 
something very quickly, it is going to escalate even further; 
absolutely.
    Senator Warner. Thank you.
    The Chairman. Senator Frist.
    Senator Frist. Thank you, Mr. Chairman.
    Sir Elton John, thank you for being here. In my opening 
remarks, I said that I really do think we have an opportunity, 
a challenge, and appropriately corrected by my colleague to my 
right, Senator Warner, an obligation. And you really represent 
a voice that goes much beyond the voice that we have as 
political figures. I speak to that because we do have access to 
money, and the case needs to be made. But your voice goes to 
what we learn when we are in Uganda and what we learn when we 
travel around the world, and that is the importance of having 
leadership, recognized public figures, presidents of countries, 
stand up and say it is important. It is something that is hard 
for politicians to do, as my colleague was saying, and your 
comments about the importance of us as representatives standing 
up, even if it is unexpected.
    Many of us have had the opportunity to meet with President 
Museveni in Uganda and Muluzi from Malawi and people who have 
stood up and, at the beginning of every speech they give, no 
matter what the subject, say ``this is the number one 
priority.''
    You see more leaders than we see as you travel around the 
world. What advice do you have for us in talking--because if 
you do not have the leaders of a country today, including this 
country but including the recipient countries where the 
incidence is high, or countries where the rate of growth is 
high--how best can we get the leadership of those countries 
involved, and what has your response been in terms of--when you 
mention your foundation, when you mention HIV/AIDS, to people 
like in South Africa, the leadership there, who might not quite 
fully want to approach the issue in the way that you do?
    Sir Elton John. I am just basically an entertainer. I am a 
quite well-known entertainer, but I am quite aware that when it 
comes to clout and speaking to politicians, I am an 
entertainer. I have no delusions about what power I have or how 
I can convince people.
    I think you have to take it to the grassroots level. For 
example, in Africa, the best way of dealing, I think, with it 
is getting people like me, or heroes, involved--people who are 
sports idols, people who are idolized by young people, people 
whom they will listen to--in Africa, soccer players, for 
example, African soccer players. If you cannot get to the 
government, and you cannot change the policy of a government, 
then start somewhere else. Start at the grassroots level. Get 
young people's attention by getting the people who are their 
heroes involved. Then they will listen.
    For example, in this country, Magic Johnson is a prime 
example. He is a great example to young people everywhere in 
this country, not only African Americans, black Americans. It 
was an incredible thing to happen; people respected him, and 
people listened to him.
    To make a difference at that level, yes, one can always go 
to the leader of a country, but it is awfully difficult. It is 
not easy for me to knock on a door and say, ``Oh, by the way, I 
am popping in for a cup of tea.'' It is not as easy as that. It 
is much easier to use one's celebrity and one's success in a 
local area to get people involved.
    This is what I intend to do in Africa when I go there, to 
take people who are idolized by African kids, whom they will 
listen to. I always think that young people will always listen. 
I think that young people are very attentive, very intelligent, 
and they will listen if they are taught and instructed the 
right way. And who better to tell them than someone whom they 
completely look up to?
    The same for Russia as well. I intend to go to Russia next 
year and do the same thing.
    So that is the way that I can do it.
    Senator Frist. I think that is very well said, and many of 
us have had the chance to work with people on this panel and go 
into the countries directly. I have tremendous faith in young 
people, and you have more access to them than we do, and we 
appreciate your work.
    Let me just close and say that what I am going to take away 
in terms of your comments today is what you said about at the 
end of the night--whether it is entertaining and what you do, 
or whether it is we as political figures today--when the lights 
go out, and when you go to bed at night, or 10 years from now 
when people look back, there is no question that the question 
is going to be asked, ``Did you do everything possible?'', and 
history is going to judge us as a Nation and as a global 
community as to how well we are both addressing and responding 
to this most devastating and destructive plague, as Sandy 
Thurman said, a plague of epidemic proportions.
    That is the image that I am going to carry away--when the 
lights go out, when we go home for recess, leave the United 
States Senate, do something else, history is going to judge how 
well we respond.
    So thank you for being here.
    Sir Elton John. Could I just say one more thing? I am 55 
years of age, and I have made a commitment for the rest of my 
life to do something for this disease. If we all come together 
to make that commitment, we will have no conscience, because we 
will have done that.
    If people come together, like this committee, like the 
people who are testifying, and we roll ourselves like a ball of 
wool and eventually get to the size of the Indiana Jones 
thing--if you remember that huge thing that went down--it is an 
unstoppable thing. Commitment en force, en masse, is an 
incredible thing.
    I have made a commitment for the rest of my life that I 
will do something for people with AIDS. If we all pull together 
and do something like that, and we all do it together, we will 
make the difference--there is no question.
    Senator Frist. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Senator Sessions.
    Senator Sessions. Thank you for that commitment. It has 
made a difference.
    I talked to a businessman who does a lot of work around the 
world, and he said that in developing nations, the absolute key 
is not to give the money too high up the ladder. If you are 
giving the money to the people doing the work, they will work 
wonderfully, and things will happen beautifully. If you give it 
too high up, it does not get to the people who do the work in 
an effective way.
    Many of you have foundations and are leading groups that 
are smaller, where you can be more effective. We are talking 
about, if we were to do what Ms. Thurman asked, tripling our 
contribution to $2.5 billion.
    Do you have any suggestions as to how we can make sure that 
that money actually reaches its greatest potential?
    Sir Elton John. I concur with you totally. What that money 
has to go toward is training people to build an infrastructure 
so that people can get the drugs they need in remote parts of 
countries, and it needs to be run on a government level. But I 
know what you are saying. I do not know how you do that, 
because I am just a singer. This is something that the 
politicians have to make sure that when the money goes to 
governments, the money is spent in the right way.
    I have said before that we are a very small AIDS 
organization; we can control where everything goes, and we do. 
We know where every penny goes. But when you get to these vast 
sums of money that we are talking about here today, you are 
going to run into those kinds of problems, and I do not 
personally know myself how you solve them, but I do concur with 
you that that is a major problem.
    Senator Sessions. Thank you.
    The Chairman. Thank you, Sir John. We know that you have 
other appointments, and we are very grateful for all the time 
you have given. If you need to be excused, we will excuse you, 
and we will take a few more minutes for questions of the other 
panelists. We hope you are not going to go beyond our call and 
that if we need you again, we can--
    Sir Elton John. Please use me as much as you feel you want 
to use me.
    The Chairman. Good. Thank you very much. If you do have to 
leave, we will understand.
    We have a short time remaining, so maybe we can each ask a 
question, and we will try to go as long as we can.
    If we say that one of the issues is the financial, would 
you say that the second one is the cultural, and what kind of 
progress are we making in terms of working through some of 
these cultural differences?
    Let us start with Dr. Mugyenyi, if you would comment, and 
then perhaps other members of the panel would like to say a 
word as well on the progress that has been made, the 
difficulties that we are facing, and any suggestions or ideas 
that you have to help us deal with these issues.
    Dr. Mugyenyi. Thank you, Senator Kennedy.
    The most important issue here is not to plan a program 
outside the developing countries and carry it over there. This 
normally faces difficulties. The most important aspect of 
culture is to work with the people, so that the planning stage 
involves the indigenous people, that is, the people who are 
going to get the aid, and the advice on how aid is to be used. 
It helps address the issue that has been brought up of the 
higher-ups not taking the money to the grassroots when the 
planning involves the people. So this is the crucial aspect of 
this, Senator.
    Another important issue in culture is information. It is 
very important that there is an atmosphere of openness in how 
AIDS money is used, so that the people themselves become the 
guardians of good use of the money, and they can only do so 
once they are informed that such amount of money is available 
and that such programs have been implemented.
    The Chairman. Can we hear from Dr. Rosenfield?
    Dr. Rosenfield. I would just like to reiterate what Peter 
has said. There is no question that we cannot take a model from 
the United States and simply impose it. We have to deal with 
local groups, and local groups have to take the leadership in 
developing a culturally sensitive or culturally appropriate 
approach to any health intervention, and particularly one as 
sensitive and difficult as the AIDS epidemic.
    We have seen a wonderful program in South Africa called 
Love Life, focused on youth, a superb program building on the 
experience of youth themselves in that particular setting. We 
need to see programs like that in each country in which funds 
are allocated.
    The Chairman. Ms. Dortzbach.
    Ms. Dortzbach. Utilizing the principles that Dr. Mugyenyi 
has described, we have seen a dramatic change in Rwanda with 
church leaders who at one time were very stigmatizing, 
reluctant to even mention the word AIDS, and said, ``It is not 
with us.'' Now, today, as a result of a lot of training, a lot 
of patience, a lot of advocacy work, there are 180 different 
support groups for people living with AIDS who are within those 
same churches.
    The Chairman. Ms. Thurman.
    Ms. Thurman. Simply to add to that that what we saw in the 
early days of the epidemic here reminds me in large part of 
what we are seeing in Africa, and that is that the response had 
to be homegrown, it had to be based in the community and then 
supported by Federal and State dollars.
    I think it addresses what Senator Sessions was saying, that 
in the Ryan White CARE Act, what made it so successful was the 
fact that the money came from the Federal Government but went 
directly into community-based organizations and not through 
some cumbersome Government process, so that the cultural 
issues, even at the domestic level, in the communities hardest-
hit early on could be dealt with in very sensitive ways.
    The Chairman. I can remember the difference in the cost. In 
San Francisco, it was about $30,000 to $35,000, and in Boston, 
about $120,000. So we found out how to really do this and do it 
right.
    Senator Clinton.
    Senator Clinton. Thank you very much.
    I want to be sure that I understand the specific 
recommendations that each of you would make to us, because as 
we attempt to craft legislation out of this committee, out of 
the Foreign Relations committee, and out of other committees 
that are involved, I hope that we fully appreciate the ideas 
that you have brought to us.
    So to that end, I just want to confirm that in your written 
testimony, Ms. Thurman, you have specific recommendations 
regarding the role that the Centers for Disease Control could 
undertake, including a treatment set-aside which would provide 
a Federal match of any private funding to expand MTCT programs. 
I understand that that is one of your recommendations. Is that 
right?
    Ms. Thurman. It is. We are recommending that at least $500 
million be given to CDC to expand their prevention efforts, and 
then also to expand their care and treatment programs and 
support and match what the private foundations that Dr. 
Rosenfield has talked about are doing.
    Again, I think this whole idea of public-private 
partnership at this point in time is very important, and the 30 
percent set-aside that we are talking about for treatment would 
include that $100 million to match what the foundations have 
done to expand the programs to prevent mother-to-child 
transmission to treat mothers and other family members.
    Senator Clinton. And that would correspond as well with Sir 
Elton's recommendation, as well as Dr. Rosenfield's 
recommendation, about private initiative being given that kind 
of match.
    Ms. Thurman. Yes.
    Senator Clinton. In addition, you recommend that HRSA, 
which is one of our Federal agencies that now does a lot of 
work under the Ryan White CARE Act, be more involved in the 
developing world; so we would use the expertise that we have 
already developed here and export that.
    Ms. Thurman. Exactly. We do not need to reinvent the wheel 
at this point.
    Senator Clinton. Third, you recommend that the committee 
authorize and try to push a workplace-based HIV/AIDS program 
through both the CDC and the Department of Labor that would be 
used in other countries to try to do workplace education along 
the lines of what has been done in Uganda, Senegal, and other 
successful programs; is that right?
    Ms. Thurman. Exactly, and that is particularly important 
where we have anywhere between 5 and 30 percent of the work 
force infected. Using organized labor and the workplace is our 
best way to reach those people.
    Senator Clinton. Similarly, both Dr. Mugyenyi and Dr. 
Rosenfield mentioned the availability and cost of AIDS drugs. 
This is a difficult challenge, but it is one that we have to 
address. I think that both with respect to the generally 
available effective AIDS drugs and the MTCT-Plus program, we 
are going to have to tackle this in one way or another. It is 
very troubling to think about the future, because certainly we 
are focusing today on Africa, but there are many experts who 
increasingly are telling us that the pandemic is alive and well 
and spreading in Asia, particularly in India, increasingly in 
China, and in Russia. So, trying to get ahead of the need for 
drugs and figure out a way to provide them in a cost-effective 
manner is critical, I assume.
    I very much appreciated Ms. Dortzbach's testimony on the 
role of microcredit and the role of family financing, which is 
something that I believe in very strongly and have worked on 
for more than--oh, my gosh, a long time--20 years, I guess. And 
I had not really thought about including microcredit as part of 
our overall comprehensive AIDS strategy until you mentioned 
that, Ms. Dortzbach. I think that is something that we really 
ought to look at, because it goes hand-in-hand with self-
sufficiency, with economic activity, which is an important part 
of dealing with this crisis. So I very much appreciate your 
description and recommendation on that.
    Mr. Chairman, I think we have some very positive 
suggestions from this panel in addition to their very moving 
testimony and their own personal commitment. I think we have 
some ideas that we can get to work on in this committee and can 
work on with other committees as well.
    Thank you.
    The Chairman. Very good. Thank you.
    Senator Frist.
    Senator Frist. Thank you, Mr. Chairman.
    I would like to come back to two questions, and one, I will 
direct to Ms. Thurman about the AIDS orphans issue, and then, 
Dr. Mugyenyi, I want to ask you about the testing component of 
linking prevention, care, and treatment with testing. When I 
was with you several months ago, the most remarkable thing that 
I learned on my last trip to Africa 2 months ago, to Uganda, to 
see, as Senator Clinton did, the tremendous service in track 
record, but also culturally-oriented service that you offer 
there--it was remarkable to me to see the change versus 3 years 
ago in terms of rapid testing, VCT, voluntary. We have 
mentioned it in the hearing this morning, but it was remarkable 
to me that we have been able to condense a test which costs $50 
to $60 in American dollars and used to take several weeks--
where you lost that ``teachable moment.'' The voluntary part 
amazed me that it worked so well. The counseling part is the 
education that we have all mentioned. The testing part, the 
technology, and the role that technology has played in taking 
an expensive test that took several weeks, where you lost the 
``teachable moment,'' you might not be able to see that 
individual once again--now, with the test down to $1.20, with 
certain sensitivity and certain specificity combined in that 1-
hour or 45-minute period, you can capture what a physician 
knows as the teachable moment where somebody who comes seeking 
information, is receptive, you can give that information and 
while you are there discuss, whether it is behavior, whether it 
is treatment options, and again, Sandy Thurman's linkage 
between prevention, care, and treatment is so critical from a 
physician's standpoint as we go forward.
    Before I have you answer that, let me ask the second 
question which has to do with the orphans. Father D'Agostino is 
in the audience today, and many of us have had the opportunity 
to visit with him on numerous occasions and have seen the 
tremendous work that he does. When you see the AIDS orphans--
and you are almost embarrassed to call them ``AIDS orphans,'' 
because you see their faces and the delight and the love that 
he has been able to give them and that they can express--yet, 
as you said in your testimony, we are going to have 40 million 
AIDS orphans in the next 40 years.
    If you could just address what we can do, and Dr. Mugyenyi, 
could you comment on the testing, the technology, and the 
impact it has had.
    Dr. Mugyenyi. Thank you, Senator Frist.
    That is a very, very important issue, because for a long 
time, it was thought that Africa would not make headway because 
it had no technological means of testing for HIV/AIDS and 
monitoring for antiretroviral drugs.
    Testing has indeed made a revolution in Africa. A person 
comes into our clinic, and just within the same day, in fact, 
within an hour, we will have had counseling, he will have had 
discussions with a few other people who are prepared to be 
available on that day, and then he will get the results on the 
same day and then see physicians in the same small center that 
you saw and be able to have a description of how to go forward 
with treatment.
    This can be repeated in many parts of Africa, and we are 
very proud that we are part of the groups that developed this 
method.
    Another very important question related to testing, Senator 
Frist, is the expensive monitoring tests. It is embarrassing, 
Senator, that these tests are now more expensive than the drugs 
themselves.
    Senator Frist. Could you tell us roughly, in terms of 
testing for VCT, how much do those little tests cost, 
approximately?
    Dr. Mugyenyi. If you use the conventional method of testing 
for CD4, you pay about $60.
    Senator Frist. And this is for the monitoring.
    Dr. Mugyenyi. Just for the CD4.
    Senator Frist. First of all, for the voluntary counseling 
and testing, when somebody comes in, HIV-positive or not, about 
how much does that cost today?
    Dr. Mugyenyi. It costs about $200 to do both CD4 and 
virology testing.
    Senator Frist. For VCT, though, for the voluntary 
counseling and testing, if somebody walks in the door, and they 
just want to know if they are HIV-positive, to do the screen 
for them costs how much?
    Dr. Mugyenyi. Oh, in our center now, it is down to $1.
    Senator Frist. One dollar. That is just unbelievable. And 
you can get the result immediately.
    Dr. Mugyenyi. Yes.
    Senator Frist. The second issue you talked about is 
monitoring, which is the immunologic monitoring over time. How 
much does that cost now?
    Dr. Mugyenyi. That is very expensive, but Senator, in my 
center, we no longer use those methods. We have, together with 
American scientists and other scientists, discovered that we 
can do effective testing using more cost-effective methods. We 
can now do it for under $30.
    Senator Frist. Thirty dollars. Is that for a year, or per 
test?
    Dr. Mugyenyi. Per test.
    Senator Frist. Per test. And how many tests per year?
    Dr. Mugyenyi. We just need two tests per year.
    Senator Frist. Thank you very much.
    Ms. Thurman. And looking at the issue of orphans, I think 
there are a lot of things that we can do. It is sort of mind-
boggling to think that we will have 40 million children 
orphaned by AIDS. Certainly, Father D'Agostino has done 
extraordinary work in the orphanage that he runs, but in 
addition to the orphanage, he has an incredible outreach 
program, and I think that that is where we have to focus most 
of our attention, because with 40 million orphans, we are going 
to have to keep them in communities. In addition to that, we 
all know from decades of study that children thrive better if 
left in their own families and in their own communities, and 
not put in institutions. That needs to be a last resort for us.
    So I think there are several things that we can do. We need 
to give the families support that are caring for orphans. We 
need to look at microfinance programs like the program that the 
First Lady of Uganda has started to mobilize, grandmothers who 
are actually inheriting the care of many orphans when their 
children die. We need to look at supporting school fees for 
children, training caregivers. I think we need to prepare the 
children for the death of their parents. That is something that 
costs very little, but in terms of their psychology development 
long-term, it is very, very important when we can to prepare 
these children for life without their parents; and again, that 
costs very, very little.
    So there are a lot of ways and very cost-effective ways 
that we can support those children and try to keep them in 
their communities when we can, but education of these children 
and school fees is going to be very important, because if they 
have no means of support, they are going to be very, very 
vulnerable. So we need to look at that impact as well.
    Dr. Rosenfield. Senator Frist, could I just add one point? 
With both the MTCT-Plus initiative and the major, much larger 
initiative of the Global Fund, we can prevent 40 million 
orphans over the next 20 years if we take this pandemic 
seriously now and put in place programs both to put MTCT alone 
in place to decrease transmission rates, treat the mothers so 
that the kids are not orphaned, and begin the broad treatment 
programs.
    I would urge the committee to support not only the 
initiatives that we have talked about, but Kofi Annan's 
eloquent call to action for his Global Fund; and the United 
States should be taking, I believe, greater leadership in the 
support of the Global Fund, because that is the long-term hope 
that we will not end up with 40 million orphaned children and 
that we will reverse the absolute death rates that exist now 
for everybody who is HIV-positive in Africa, Asia and 
elsewhere.
    I do agree, Senator Kennedy, that the figures in India and 
China are probably significant underestimates of how 
significantly that epidemic has already reached South and 
Southeast Asia.
    So just think--if India had 5 percent seropositivity, well 
below some of the rates in Africa, with a billion people, the 
mathematics there are just mind-boggling. And we are heading 
there if we do not get ahead of this process, both in 
prevention and care.
    The Chairman. The vote has started, so we have about 4 or 5 
minutes.
    Senator Warner.
    Senator Warner. I will be very brief.
    Dr. Rosenfield, we are going back and forth, 
understandably, between the problems abroad and the problems 
here at home. Ms. Thurman had an opportunity to respond to 
questions from Senator Kennedy about the domestic situation. Do 
you wish to add anything about the domestic situation?
    Dr. Rosenfield. Yes. I think it is obviously at a different 
level than in Africa, but it is a major issue. It has become 
predominantly an issue of people of color. I chair the New York 
State AIDS Advisory Council, and we deal with this all the 
time. We continue to have deaths. People do break through from 
treatment.
    We need a greater focus and a greater allocation of 
resources to those who are at highest risk in this epidemic in 
our country, and that includes the IV drug-using populations, 
those exposed to those drug-using populations. We see a return 
among men who have sex with men, particularly younger people 
who are not believing the stories of older people.
    So we do have a heavy challenge still in our own country as 
well.
    Senator Warner. Thank you.
    Dr. Mugyenyi, I mentioned the political and military 
instability in a number of nations. Can you comment on that? It 
is the inability to raise and sustain not only internal 
military forces but internal police and otherwise, which are 
essential to any government to carry out its policies.
    Am I correct that this disease is a direct contributor to a 
great deal of instability in both of those areas, political and 
military?
    Dr. Mugyenyi. Yes, Senator. This is a very destabilizing 
factor in our part of the world. The soldiers who are sick are 
not able to defend their countries; the lack of drugs for a 
disease that is most important to the people is causing 
agitation. You have seen the situation in Southern Africa. It 
is the most important political issue after being the most 
important health issue.
    So you are absolutely right, Senator, that this is not only 
a health factor but also a highly destabilizing factor in our 
part of the world.
    Senator Warner. Mr. Chairman, if those witnesses with us 
today or others following this important hearing have further 
contributions in that area of political-military instability, I 
would be happy to review them, and suggest that portions might 
go into today's record.
    The Chairman. Thank you.
    Senator Sessions.
    Senator Sessions. Thank you, Mr. Chairman.
    Dr. Rosenfield, maybe we could summarize a little bit here 
on some of the things that we have discussed.
    How much does it cost--well, let me ask this--what 
percentage of children with untreated mothers who have AIDS are 
born with the disease, and what can be done if the mother has 
the medication, and how much progress in reducing that 
infection rate can be achieved?
    Dr. Rosenfield. Without treatment, the transition rate is 
estimated to be somewhere between 25 and 40 percent. With the 
simple nevirapine therapy to the mother, a single dose, and the 
single dose to the baby, we can beat that by at least 50 
percent.
    Senator Sessions. And that is a $4 dose, approximately? How 
much is it?
    Dr. Rosenfield. It is something in that range. So we can 
change that by at least 50 percent.
    Senator Sessions. And Ms. Thurman, I think you were 
suggesting that we need to go further than that and deal with 
the mothers and fathers who are dying of AIDS, and that 
treatment could prevent these children from becoming orphans.
    Ms. Thurman. It is true. I think that if we treat the 
mother--and hopefully the fathers, because it creates bad 
family dynamics if you are treating the mother and not the 
father--but certainly treating the mother, we again know from 
years of research that the longer we can keep those infants 
with their mothers, the more viable they will be in the long 
term. So that is what we are asking CDC and what Dr. 
Rosenfield's MTCT-Plus program aims to do, and that is to 
provide treatment to mothers and other family members so we do 
not create orphans, so we keep families together. It is about 
celebrating and supporting the families.
    Senator Sessions. Let me ask this. What percentage of 
pregnant women with AIDS are being treated with the drugs? Does 
anyone konw that?
    Dr. Rosenfield. With nevirapine today?
    Senator Sessions. In Africa.
    Dr. Rosenfield. It is a very small percentage. The program 
is only 3 to 4 years old. The Glaser Foundation has taken a 
lead in this, and UNICEF and others are actively involved, but 
it is still a small program and in need of great additional 
resources.
    I could not give you a percentage, but it is a very small 
percentage of the total number of women who are currently HIV-
positive in Africa.
    Senator Sessions. So with a $4 treatment, we could 
dramatically reduce the number of infants born with AIDS, and 
we are just not reaching those pepole.
    Dr. Rosenfield. Yes. Certainly, additional funding is 
needed, but the groups, again, like the Glaser Foundation, 
UNICEF, Medins Sans Frontiers, CDC, and others, are moving as 
quickly as they can to work with governments to try to expand 
these programs.
    Senator Sessions. Well, that is a challenge.
    Thank you.
    The Chairman. Thank you very much.
    Again, all of you have been enormously interesting. We will 
have all of this as an amendment to the Foreign Relations 
Committee legislation that will be considered. Also, we will 
all be supportive in terms of these funding mechanisms, and it 
may come out somewhat differently in terms of different members 
of the committee, but I think you have a strong sense that we 
are all going to do as much as we possibly can. That is 
probably the best way we can thank you very much for a really 
extraordinary presentation.
    We hope that as many of our colleagues as possible will 
read through the record and review what has been said, because 
it is enormously persuasive and compelling.
    I just want to mention that we do have here with us today 
Ann Blackmun and her son Christophe. Ann and her son have 
worked tirelessly to bring attention to issues of families and 
children with AIDS. Christophe recently focused on the plight 
of children with AIDS in Kenya, and did a very outstanding 
documentary on that. We are very thankful that they could be 
with us today.
    There being no further business, the committee will stand 
in recess.
    [Whereupon, at 12:19 p.m., the committee was adjourned.]
  

                                
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