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35–621 PDF 2007

HIV PREVENTION: HOW EFFECTIVE IS THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF

[PEPFAR]

HEARING

BEFORE THE

SUBCOMMITTEE ON NATIONAL SECURITY,

EMERGING THREATS, AND INTERNATIONAL

RELATIONS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

SEPTEMBER 6, 2006

Serial No. 109–239

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

TOM DAVIS, Virginia, Chairman

CHRISTOPHER SHAYS, Connecticut

DAN BURTON, Indiana

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

GIL GUTKNECHT, Minnesota

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

CANDICE S. MILLER, Michigan

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

JON C. PORTER, Nevada

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

CHARLES W. DENT, Pennsylvania

VIRGINIA FOXX, North Carolina

JEAN SCHMIDT, Ohio

BRIAN P. BILBRAY, California

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. DUTCH RUPPERSBERGER, Maryland

BRIAN HIGGINS, New York

ELEANOR HOLMES NORTON, District of

Columbia

———

BERNARD SANDERS, Vermont

(Independent)

DAVID MARIN, Staff Director

LAWRENCE HALLORAN, Deputy Staff Director

BENJAMIN CHANCE, Chief Clerk

PHIL BARNETT, Minority Chief of Staff/Chief Counsel

SUBCOMMITTEE ON NATIONAL SECURITY, EMERGING THREATS, AND INTERNATIONAL

RELATIONS

CHRISTOPHER SHAYS, Connecticut, Chairman

KENNY MARCHANT, Texas

DAN BURTON, Indiana

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEVEN C. LATOURETTE, Ohio

TODD RUSSELL PLATTS, Pennsylvania

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

JON C. PORTER, Nevada

CHARLES W. DENT, Pennsylvania

DENNIS J. KUCINICH, Ohio

TOM LANTOS, California

BERNARD SANDERS, Vermont

CAROLYN B. MALONEY, New York

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. DUTCH RUPPERSBERGER, Maryland

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

EX OFFICIO

TOM DAVIS, Virginia HENRY A. WAXMAN, California

R. NICHOLAS PALARINO, Staff Director

BETH DANIEL, Professional Staff Member

ROBERT A. BRIGGS, Clerk

ANDREW SU, Minority Professional Staff Member

(III)

C O N T E N T S

Page

Hearing held on September 6, 2006 ....................................................................... 1

Statement of:

Dybul, Mark R., U.S. Global AIDS Coordinator, U.S. Department of

State; and Kent Hill, Assistant Administrator, Bureau for Global

Health, U.S. Agency for International Development ................................. 16

Dybul, Mark R. .......................................................................................... 16

Hill, Kent ................................................................................................... 27

Gootnick, David, Director, International Affairs and Trade, Government

Accountability Office; Helene Gayle, president and chief executive officer, Care USA; Lucy Sawere Nkya, member of Tanzanian Parliament

(MP, Women Special Seats), medical chairperson, Medical Board of

St. Mary’s Hospital Morogoro, director, Faraja Trust Fund; and Edward

C. Green, senior research scientist, Harvard Center for Population

and Development Studies ............................................................................. 57

Gayle, Helene ............................................................................................. 85

Green, Edward C. ...................................................................................... 119

Gootnick, David ......................................................................................... 57

Nkya, Lucy Sawere ................................................................................... 111

Letters, statements, etc., submitted for the record by:

Dybul, Mark R., U.S. Global AIDS Coordinator, U.S. Department of

State, prepared statement of ....................................................................... 21

Gayle, Helene, president and chief executive officer, Care USA, prepared

statement of ................................................................................................... 89

Gootnick, David, Director, International Affairs and Trade, Government

Accountability Office, prepared statement of ............................................. 60

Green, Edward C., senior research scientist, Harvard Center for Population and Development Studies, prepared statement of .......................... 122

Hill, Kent, Assistant Administrator, Bureau for Global Health, U.S.

Agency for International Development, prepared statement of ................ 30

Kucinich, Hon. Dennis J., a Representative in Congress from the State

of Ohio, prepared statement of .................................................................... 143

Lee, Hon. Barbara, a Representative in Congress from the State of California, prepared statement of ...................................................................... 55

Nkya, Lucy Sawere, member of Tanzanian Parliament (MP, Women Special Seats), medical chairperson, Medical Board of St. Mary’s Hospital

Morogoro, director, Faraja Trust Fund, prepared statement of ................ 115

Shays, Hon. Christopher, a Representative in Congress from the State

of Connecticut, prepared statement of ........................................................ 3

Waxman, Hon. Henry A., a Representative in Congress from the State

of California, prepared statement of ........................................................... 8

(1)

HIV PREVENTION: HOW EFFECTIVE IS THE

PRESIDENT’S EMERGENCY PLAN FOR AIDS

RELIEF [PEPFAR]

WEDNESDAY, SEPTEMBER 6, 2006

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON NATIONAL SECURITY, EMERGING

THREATS, AND INTERNATIONAL RELATIONS,

COMMITTEE ON GOVERNMENT REFORM,

Washington, DC.

The subcommittee met, pursuant to notice, at 1:07 p.m., in room

2154, Rayburn House Office Building, Hon. Christopher Shays

(chairman of the subcommittee) presiding.

Present: Representatives Shays, Duncan, and Waxman (ex officio).

Staff present: Beth Daniel, professional staff member; Nicholas

R. Palarino, Ph.D., staff director; Robert Briggs, analyst; Naomi

Seller, minority counsel; Andrew Su, minority professional staff

member; Earley Green, minority chief clerk; and Jean Gosa, minority assistant clerk.

Mr. SHAYS. A quorum being present, the Subcommittee on National Security, Emerging Threats, and International Relations

hearing entitled, ‘‘HIV Prevention: How Effective is the President’s

Emergency Plan for AIDS Relief [PEPFAR]’’ is called to order.

In 1981, scientists diagnosed the first cases of the disease we

now call HIV/AIDS, Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome. Today, 25 years later, nearly 40 million people live with HIV/AIDS. Worldwide last year, 4.1 million

people were newly infected with HIV, and 2.8 million people died

from AIDS, of whom 570,000 were children. A third of these deaths

occurred in Sub-Saharan Africa.

A January 2000 U.S. Central Intelligence Agency National Intelligence Estimate warns HIV/AIDS could deplete a quarter of the

populations of certain countries. There is no cure for the disease.

The United States has committed massive amounts of foreign assistance to fight HIV/AIDS. After Congress passed the Leadership

Act of 2003, President Bush announced a $15 billion, 5-year initiative known as PEPFAR, the President’s Emergency Plan for AIDS

Relief. PEPFAR fights HIV/AIDS through initiatives in prevention,

treatment and care.

By 2010, the goal of PEPFAR is to prevent 7 million new infections, support treatment for 2 million HIV-infected people and provide care for 10 million people affected by HIV/AIDS, including orphans and vulnerable children. Multiple branches of the U.S. GovVerDate 11-MAY-2000 10:03 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 C:\DOCS\35621.TXT HGOVREF1 PsN: HGOVREF1
2

ernment are engaged in this vast effort, including the Department

of State, U.S. Agency for International Development, Health and

Human Services, the Department of Defense, and the Peace Corps.

PEPFAR assistance will eventually reach 120 countries, but concentrates the bulk of its funds in 15 hardest hit focus countries,

most of which are in Sub-Saharan Africa.

Today, we examine PEPFAR’s prevention component. The 2003

Leadership Act, which authorized PEPFAR, recommended and now

requires 20 percent of total PEPFAR funds be spent on HIV prevention. The act endorses HIV sexual transmission prevention

through the model for Abstinence, Being Faithful and Correct and

Consistent Use of Condoms, known for short as ABC, and includes

a spending requirement that one-third of prevention funds go to abstinence-until-marriage initiatives. This spending requirement has

come under intense scrutiny as a conservative political vehicle

rather than a scientifically based policy.

Supporters of ABC contend it is evidence based and shows promising results. Critics assert the spending requirement is an arbitrary figure that ignores human nature and hinders local ability to

respond to the epidemic appropriately in each different country.

Others argue the key is integration of different prevention methods

to create comprehensive initiatives that reach as many as possible,

as effectively as possible, and flexibility so local implementers can

respond to the specific conditions where they work.

This June, I joined Congresswoman Barbara Lee and others in

introducing the Protection Against Transmission of HIV for Women

and Youth, referred to as PATHWAY, Act of 2006, which includes

a provision to lift the abstinence-until-marriage funding earmark

from PEPFAR.

Our witnesses today represent a broad spectrum of opinion and

world-class expertise in their respective fields. We welcome Ambassador Mark Dybul, Global AIDS Coordinator at the Department of

State, and the Honorable Kent Hill, head of Global Health at the

U.S. Agency for International Development.

We also welcome our second panel, including Dr. David Gootnick

of the Government Accountability Office, Dr. Helene Gayle from

CARE USA, Dr. Edward Green from Harvard University, and a

special welcome to Dr. Lucy Sawere Nkya, a member of Parliament

from Tanzania and a long time luminary in HIV/AIDS work. I will

just say she’s one of the most impressive persons I have ever met.

HIV/AIDS is a pandemic that has produced consequences unimaginable 25 years ago. Today, we need to imagine that we can

conquer this disease. The world needs PEPFAR and other programs like it to fight HIV/AIDS. We must make sure our funding

is responsive, and that the money is being used sustainably and

wisely.

That concludes my statement. At this time I would call on Mr.

Waxman, the ranking member of the full committee.

[The prepared statement of Hon. Christopher Shays follows:]

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Mr. WAXMAN. Thank you very much, Mr. Chairman.

We’re here to discuss the progress of prevention programs under

the U.S. Global AIDS Program, and I want to thank the chairman

for holding this important hearing, and for all of our witnesses for

coming here to share their experience and expertise.

The President’s Emergency Plan for AIDS Relief has made important progress in some areas. In particular, U.S. assistance has

helped bring the number of people getting treatment in the 15

focus countries from a few thousand to over 1 million. I applaud

the work of Dr. Dybul and Mr. Hill and all of the in-country staff

contributing to this effort.

But worldwide, for each person who gained access to HIV treatment last year, seven more people became infected with HIV. There

is no way for the pace of treatment access to keep up with that rate

of new infections.

So as we pass the halfway point of this first 5 years of this program, it’s time that Congress take a serious look at prevention. We

need to examine what’s working and what isn’t. We need to identify programs that are most effective in reducing vulnerabilities

and risk behaviors, and we need to figure out why they work and

where they work, and we need to replicate the most successful

ones.

Today, we’re going to look in particular at the results of a GAO

investigation into one element of U.S. HIV prevention policy. It’s

the requirement that one-third of prevention funds be spent on Abstinence and Be Faithful programs. When the House debated the

abstinence requirements, the focus of the debate was the proper

balance of abstinence funding, be-faithful funding and condom

funding to stop the transmission of HIV.

As depicted in the chart, we had a debate over whether one-third

of the funds should be designated for abstinence or if instead we

should let the experts determine the right balance. Like several of

my colleagues, I felt strongly that we should let the experts decide.

But what the GAO report makes clear is that we weren’t discussing

the right pie, we were focused on three interventions that address

sexual transmission. And the behavior changes these programs

tried to create, delayed sexual debut, partner reduction and condom

use, are crucial elements of HIV prevention, but we didn’t discuss

all of the other elements of prevention. We didn’t talk about

antiretroviral therapy to reduce mother-to-child transmission. We

didn’t talk about blood supply safety. We didn’t talk about the medical injection safety. We didn’t talk about programs that address

the myriad social problems that render people vulnerable to HIV

infection. And we didn’t talk about the possibility of new types of

interventions like male circumcision.

When we look at the full picture, as shown in this second chart,

a few things are much clearer. First, when we say that one-third

of prevention funds have to go to abstinence programs, we cut into

many other types of prevention programs. The administration has

determined that the be-faithful message is linked to the abstinence

message, and as reported to us, the programs that cover both abstinence and faithfulness will be counted toward the one-third requirement.

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But other interventions, like those that save the lives of babies

born to women with HIV, have to compete for the rest of the prevention funds. As GAO found, countries have had to restrict funding for many other kinds of prevention programs to meet the abstinence requirement.

What’s also clear from this chart is that HIV prevention is extremely complicated. There is no question that determining the

right mix for any given country requires an enormous amount of

time and expertise. No formula that we try to write in Congress

will ever be right for the epidemiology and culture of each country.

It’s difficult to overstate the role of the USAIDS program. We are

the biggest donor of the world. Our policies carry great weight and

very strong sway over countries and individual grantees. We must

not shrug off the responsibility we have to pursue the best evidence-based prevention policies.

So it’s time for us to stop focusing on arbitrary formulations and

have a meaningful discussion of U.S. prevention policy that extends

beyond ideology and rhetoric and domestic politics, and I hope we

can start this debate today.

Thank you very much.

[The prepared statement of Hon. Henry A. Waxman follows:]

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Mr. SHAYS. I thank the gentleman.

At this time, Mr. Duncan.

Mr. DUNCAN. I have no statement, Mr. Chairman, but I do think

this is a very important topic, and I’m pleased that you would call

a hearing in a continuation of many important hearings in your

subcommittee. Thank you very much.

Mr. SHAYS. I thank the gentleman very much.

Let me take care of some business before calling on our first

panel.

I ask unanimous consent that all members of the subcommittee

be permitted to place an opening statement in the record and that

the record remain open for 3 days for that purpose, and without objection, so ordered.

I ask future unanimous consent that all witnesses be permitted

to include their written statements in the record, and without objection, so ordered.

And at this time the Chair would acknowledge our first panel.

We have Ambassador Mark Dybul, U.S. Global AIDS Coordinator,

U.S. Department of State, and the Honorable Kent Hill, Assistant

Administrator, Bureau for Global Health, U.S. Agency for International Development. And as you gentlemen know, we swear in

all of our witnesses, and if you will just stand, I’ll swear you in.

[Witnesses sworn.]

Mr. SHAYS. I’ll note for the record that both of our witnesses

have responded in the affirmative.

It’s truly an honor to have both of you here. You are real experts

doing very important work. And I know the committee welcomes

you and looks forward to the dialog that we’ll have.

At this time, Mr. Dybul—Ambassador, excuse me—we’ll ask you

to make an opening statement. What we do with the clock, we have

5 minutes, but we roll it over another 5 minutes. So we’ll ask you

not to be more than 10, but somewhere in between 5 and 10 would

be helpful.

Thank you.

STATEMENTS OF MARK R. DYBUL, U.S. GLOBAL AIDS COORDINATOR, U.S. DEPARTMENT OF STATE; AND KENT HILL, ASSISTANT ADMINISTRATOR, BUREAU FOR GLOBAL HEALTH,

U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT

STATEMENT OF MARK R. DYBUL

Ambassador DYBUL. Thank you, Mr. Chairman, Congressman

Waxman, and Congressman Duncan. Thank you for this opportunity to discuss President Bush’s unprecedented emergency plan

for AIDS relief. We’ve been grateful for the strong bipartisan support of Congress, including members of this subcommittee.

I’m pleased to be here with Dr. Hill, who leads the U.S. Agency

for International Development work toimplement PEPFAR.

Fundamentally, it’s the generosity of the American people that

has created the largest international health initiative in history

dedicated to a specific disease.

In looking at just 15 focus countries of the more than 120 countries where we have worked through bilateral programs in the first

2 years of the Emergency Plan, we’ve seen remarkable results to

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date, as both the chairman and Mr. Waxman have noticed. We supported treatment for over 560,000 people, 61 percent of whom are

women, and 8 percent of whom are children. We have supported

care for 3 million, including 1.2 million orphans and vulnerable

children. We’ve supported counseling and testing for 13.6 million,

69 percent of whom are female.

And these figures do not include work in other countries with bilateral U.S. Government programs under the Emergency Plan.

More importantly, the American people’s support for the programs

of the Global Fund to Fight Aids, Tuberculosis and Malaria, other

bilateral programs and the Global Fund are integral components of

PEPFAR.

Yet as was noted, treatment and care for those already infected

with HIV/AIDS are not enough. If we do not slow the rate of infections, it will be impossible to sustain the resources, financial,

human, institutional, for care and treatment of an ever expanding

pool of infected individuals. Ultimately, effective prevention is the

only way to achieve the elusive goal of an AIDS free generation.

More than 31⁄2 years ago, President Bush had the vision to insist

that prevention, treatment and care be addressed together, an idea

that now commands wide respect. The lessons learned from the

Emergency Plan are now helping to fuel transformation of the HIV/

AIDS responses in nations around the world.

PEPFAR’s unparalleled financial commitment has permitted the

U.S. Government to support a balanced, multi-dimensional approach, one that was not possible at pre-PEPFAR funding levels.

The total annual spending on HIV/AIDS prevention as well as

treatment and care has continually increased since the passage of

the Leadership Act.

If Congress enacts the President’s request for $4 billion for HIV/

AIDS in 2007, that will be the fourth straight year of increased

funding under the President’s plan. In comparison with the fiscal

year 2001 total of $840 million for global HIV/AIDS, these PEPFAR

funding levels represent a quantum leap.

Even with the massive and highly successful scale-up of treatment and care services with PEPFAR support, PEPFAR

preventionfunding in the focus countries has grown substantially

from 2004 to 2006, yet there has been a significant constraint on

resources in the focus countries, as was noted in the GAO report.

Almost $527 million from focus country programs has been redirected to the Global Fund, and other components of the Emergency

Plan over PEPFAR’s first 3 years.

The effectiveof this trend has been to force country teams to

make difficult tradeoffs. In 2007 and beyond, full funding for focus

country activities is essential if PEPFAR is to meet its 2–7–10

goals, including the prevention goal.

If I accomplish nothing else today, I hope I will be able to persuade you of the importance of full funding, meeting the President’s request for the focus countries to ensure effective prevention.

Now if I could, I’d like to turn briefly to what constitutes effective prevention.

As Mr. Waxman noted, PEPFAR—and effective prevention is a

complicated matter. PEPFAR supports the most comprehensive

prevention strategy in the world, including interventions for sexual

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transmission, prevention of mother-to-child transmission, safe

blood, safe medical injections, all the pieces of the pie that are up

there. However, prevention must squarely address the reality that

the overwhelming majority of cases of HIV/AIDS infection are due

to sexual activity, 80 percent worldwide.

Effective prevention must address risky sexual behavior because

it is the heart of this epidemic.

The people of Africa have been leaders in developing a prevention strategy that responds to the special challenges that they face,

the ABC approach, which stands for Abstinence, Being Faithful

and Correct and Consistent Use of Condoms. In fact, the strategies

of many nations in Africa and elsewhere included the ABC approach, delivered in culturally sensitive ways, long before the advent of the Emergency Plan.

The past year has been a particularly important moment in the

effort for sustainable development. Impressive new demographic

health survey evidence from a growing number of nations is expanding the evidence base for the ABC strategy and generalized

epidemics such as those in most Sub-Saharan Africa.

Recent data from Kenya, Zimbabwe and urban Haiti show declines in HIV prevalence. A new study has concluded that these reductions in prevalence do not simply represent the natural course

of these nations’ epidemics, but can only be explained by changes

in sexual behavior.

In Kenya, the Ministry of Health estimated that prevalence

dropped by 30 percent over a 5-year period ending in 2003. The decline correlated with a broad reduction in sexual behavior, including increased male faithfulness, as measured by a 50 percent reduction in young men with multiple sexual partners; primary abstinence, as measured by delayed sexual debut; and secondary abstinence, as measured by those that have been sexually active but refrained from activity over the past year, and increased use of

condoms by young women who engage in risky activity.

In an area in Zimbabwe, the journal Science reported a 23 percent reduction in prevalence among young men, and a remarkable

49 percent decline among young women, also during the 5-year period ending in 2003. Again, the article correlates significant behavior change consistent with ABC with the decrease in prevalence.

Because of the data, ABC is now recognized as the most effective

strategy to prevent HIV/AIDS in generalized epidemics. The GAO

report notes the consensus among U.S. Government field personnel

that ABC is the right approach to prevention.

To the extent any controversy remains around ABC, I believe

that it stems from a misunderstanding. ABC is not a narrow onesize-fits-all recipe, it encompasses a wide variety of approaches

through a myriad of factors that lead to sexual transmission. For

example, the Emergency Plan recognizes the critical need to address the inequalities among women and men that influence behavior change necessary to prevent HIV. PEPFAR-supported ABC programs address gender issues, to include violence against women,

cross generational sex and transactional sex. Such approaches are

not in conflict with ABC, they are integral to it.

Some of the most striking data presented at our recent implementers meeting in Durban concerned behavior change by men, the

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B, or being faithful element of the ABC strategy. In a number of

places men have begun toreduce their number of sexual partners

through ABC interventions.

The ABC programs also address the issue of prevention for HIV

positive people, helping infected people to choose whether to abstain from activity, to be faithful to a single partner whose status

is known, and use of condoms. ABC programs offers people information on how alcohol abuse can lead them into risky sexual behavior, and work with HIV positive injecting drug users so they

can avoid sexual transmission of HIV/AIDS.

And ABC programs link people to counseling and testing because

we know people who know their HIV status are more likely to protect themselves and others from infection.

Now of course we also support national strategies to prevent

mother-to-child transmission and transmission through unsafe

blood and medical injections, in addition to programs that teach

ABC messages to injection drug users. The Emergency Plan supports programs that work with drug users to free them from their

addiction through prevention and education, and through substitution therapy, an approach that has been scientifically proven to

reduce HIV/AIDS infection while providing clinical treatment for

addiction.

I’d like to address the effect of the congressional prevention directive. The authorizing legislation recommends that 20 percent of

funds in the focus country be allocated for prevention, and directs

that at least 33 percent of prevention funding be allocated to abstinence-until-marriage programs. As has been noted, we count programs that focus on abstinence and faithfulness for this purpose,

and this 33 percent requirement is applied to all countries collectively, and PEPFAR has met it.

The legislation’s emphasis on ABC activities has been an important factor on the fundamental and needed shift in U.S. Government prevention strategy from a primarily C approach prior to

PEPFAR to a balanced ABC strategy. PEPFAR has followed Congress’ mandate that it is possible and necessary to strongly emphasize A, B and C.

The congressional directive, which itself reflects an evidencebased public health understanding of the importance of ABC, has

helped to support PEPFAR’s field personnel in appropriately broadening the range of prevention efforts. The directive has helped

PEPFAR to align itself with the host nations, of which ABC is a

key element.

PEPFAR does offer each focus country team the opportunity to

propose and provide justification for a different prevention funding

allocation based on the circumstances in that country. To date, all

such justifications have been approved without requiring other

countries to make offsetting judgments to their proposed prevention allocations.

It is also important to remember that the U.S. Government is not

the only source of funding in-country, and that partners can seek

funding from other sources to balance their mix of prevention interventions if they find that necessary. In fact, money does not always

follow the evidence. As the Minister of Health in Namibia noted in

a recent letter to the editor of the Lancet, PEPFAR support for AB

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is needed to ensure the balanced ABC approach that Namibia

seeks, and this is because other international partners primarily

support C interventions.

Last, let me address the issue of how we are monitoring and

evaluating our prevention efforts. We strongly believe that we need

to focus not only on the inputs but on results, the number of HIV

infections averted to PEPFAR interventions.

Obviously we cannot measure directly the number of infections

that would have occurred without U.S. Government support. One

area for prevention for which we are using a model to estimate infections averted is prevention of mother-to-child transmission, or

PMT CT.

Through March 2006, we supported PMTCT services for more

than 4.5 million pregnancies. It is noteworthy that the number of

women served grew dramatically from 821,000 in the first half of

2005 to almost 1.3 million in the first half of 2006, a 57 percent

increase. This is clearly related to the 59 percent increase in

PMTCT funding managed in the focus countries over the course of

PEPFAR, from $44 million in 2004 to $71 million this year. And

these numbers do not include HIV positive pregnant women who

receive other PEPFAR supported services, including treatment,

care, counseling and testing, and other prevention interventions.

In over 342 pregnancies, the women were identified as HIV positive and given antiretroviral prophylaxis to prevent infections of

their children. Using an internationally agreed model, we estimate

that this intervention averted approximately 65,100 infant infections through March of this year.

For prevention as a whole, including sexual and medical transmission, we are working to develop the best possible models to

allow us to estimate the numbers of infections that PEPFAR supported programs have averted.

Mr. Chairman, there has been a sense of fatalism about HIV prevention in many quarters; it is long past time to discard that attitude. The world community must come alongside governments,

civil society, faith-based organizations and others to support their

leadership in the sustainability of the HIV prevention programs

through effective prevention. The U.S. Government, for our part,

considers it a privilege to do so.

The initial years of the Emergency Plan have demonstrated that

prevention can work in many of the world’s most difficult places.

Through PEPFAR, the American people have become leaders in the

world effort to turn the tide against HIV/AIDS.

Mr. Chairman, thank you very much, and I’d be happy to address your questions.

[The prepared statement of Ambassador Dybul follows:]

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Mr. SHAYS. Thank you very much. Dr. Hill.

STATEMENT OF KENT HILL

Dr. HILL. Mr. Chairman, and members of the subcommittee, as

Assistant Administrator of the Bureau for Global Health at USAID,

it is my privilege to testify on the importance of prevention in the

President’s Emergency Plan for AIDS, and to testify with my

friend, Ambassador Dybul.

This discussion is particularly timely as only 3 weeks ago the

16th International AIDS Conference came to a close in Toronto,

Canada. Against the backdrop of that conference, I returned to

Washington with three overarching themes dominant in my thinking.

First, the United States is recognized as a global leader in the

fight against HIV/AIDS. The sheer magnitude of the resources the

United States has committed to this single disease is unprecedented beyond that of any other nation in the world.

Second, the fight against HIV/AIDS is far from over. Four million

new infections every year means that we must markedly scale up

and strengthen the prevention of new HIV infections globally.

And third, although opinions can and do diverge regarding the

relative importance of various prevention interventions, we must

differentiate between legitimate debate and the much more common misinformation so often associated with discussion of the U.S.

endorsement of ABC, the abstinence or delay of sexual debut, the

be faithful or at least the reduction of partners, and the correct and

consistent use of condoms.

As Ambassador Dybul said, the ABC approach is an evidencebased, flexible approach and common sense based strategy which

plays a major role in stemming the tide of HIV/AIDS pandemic.

It is too important to be bogged down in the politics of passion,

too much is at stake, too many lives hang in the balance, too many

children are vulnerable to become orphans if we fail in our prevention efforts. And it should be noted that one way to raise the quality of the discussion of ABC prevention intervention is to absolutely

insist that it take place in the context of gender issues. After all,

many of the problems associated with the spread of HIV are intimately connected with the absence of gender equity, the presence

of gender-based violence and coercion typical of transactional and

transgenerational sex. For all too many young girls, abstinence is

not about being morally conservative, it is about having the right

to abstain. The double standards of men who are unfaithful while

their wives are is a gender equity issue. In short, AB interventions

much be seen as fundamentally linked to gender and equality

issues, a topic which can unite left and right, liberals and conservatives. We need to focus on the common ground.

The ABC approach to HIV prevention is good public health,

based on respect for local culture. As has been stated, is it an African solution developed in Africa, not in the United States, and it

has universally adaptable themes. To amplify this point, in May

2006 the Southern Africa Development Community, an alliance of

several countries in southern Africa, convened an expert think tank

meeting to identify and mobilize key regional priorities of HIV prevention. The media report characterized multiple and concurrent

28

sexual partnerships as essential drivers of the HIV/AIDS epidemic

in the southern Africa region. They recommended in light of this

fact that priority be given to the interventions that reduce the

number of multiple and concurrent partnerships, address male behavior involvement, increase consistent and correct condom use,

and continue programming around delayed sexual debut. Clearly

these are African derived interventions that address ABC behaviors.

In the field, we are taking steps to find out how well our programs are working. In addition to our normal evaluation of program effectiveness, USAID is leading U.S. Government agencies in

an independent evaluation, one not done by USG folks, of some

PEPFAR supported ABC programs. An expert meeting was convened to develop new evaluation tools to measure program implementation and strengths. This will be followed by a longer term

program evaluation that will be multi-country in nature, and will

provide important information on program strengths and outcomes.

We’re excited about this progress and look forward to the findings

which will be used to improve program performance.

One promising, yet overlooked aspect of the Emergency Plan, is

its increased attention to issues of male behavior, which lie at the

heart of women’s sexual vulnerability and sexual coercion. I’d like

to give you some examples of what I’m talking about here.

In South Africa, the Emergency Plan works with the Institute

For Health and Development Communication’s Soul City, the most

expansive HIV/AIDS communication intervention in the country,

reaching about 80 percent of the population. Soul City emphasizes

the role of men in parenting and caring. It challenges social norms

around men’s perceived right to sex, sexual violence, and

intergenerational sex. There is statistical correlation between exposure to Soul City programming and improved norms and values

amongst men.

Also in South Africa, the Emergency Plan supports a very successful male involvement program known as Men As Partners. In

addition to dealing HIV/AIDS prevention issues that include masculinity, stigma, domestic violence, men are encouraged to assume

a larger share of responsibilities for family and community care by

spending more time with their children, mentoring young boys in

the community, and visiting terminally ill AIDS patients.

Or take for example, Zambia. The United States is working with

the Zambian Defense Force to train peer educators and commanding officers to raise awareness among men in the military about

the threat posed by HIV/AIDS and to enlist their support in addressing it. Training workshops cover basic facts about HIV/AIDS

and its impact, including transmission, prevention, stigma, sexuality, gender, positive living, counseling, testing and care.

I’m going to skip Uganda. A lot has been said about that before,

but there are a lot of good things that can be said here, and go on

to Namibia.

The Lifeline Childline program addresses the root causes of gender violence. It uses age-appropriate messages to teach boys—as

well as girls—about HIV/AIDS sexual abuse, domestic violence, and

the resources available to vulnerable children through specialized

counseling and other services.

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And I’d like to conclude by underscoring the 2004 Lancet commentary on finding common ground. This was a piece signed by

150 AIDS experts, some in this room, from around the world, noting that the ABC approach can play an important role in reducing

the prevalence in a generalized epidemic, and that partner reduction is of central epidemiological importance in achieving large

scale HIV incidents reduction, both in generalized and in more concentrated epidemics.

Through partnership with host nations, effective programs for

HIV prevention are possible even in the most difficult places. We

will continue to support this common ground as we continue our

massive response to HIV and AIDS.

Congressional commitment to a comprehensive HIV prevention

strategy is the correct approach, and one clearly supported by the

evidence. Thank you.

[The prepared statement of Dr. Hill follows:]

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Mr. SHAYS. Thank you very much.

Mr. Duncan, we’ll have you start off.

Mr. DUNCAN. Well, thank you very much, Mr. Chairman.

Let me ask this. We have a GAO report that says that the

PEPFAR prevention budget is $322 million, and that’s 20 percent

of the total PEPFAR budget, which would mean the total PEPFAR

budget would be approximately $1.6 billion; is that close to being

correct?

Ambassador DYBUL. Yes, sir, that is correct, in terms of the 15

focus countries that were mentioned by the chairman. The entire

PEPFAR budget encompasses other bilateral programs, it encompasses international research on HIV/AIDS, and it also encompasses our contribution to the Global Fund for AIDS, tuberculosis

and malaria, which is substantial. So it would be $1.6 of $3.2 billion, approximately.

Mr. DUNCAN. According to CRS, it says we’re giving about $350

million, roughly, to the Global Fund over the last couple of years,

each year.

Ambassador DYBUL. Correct.

Mr. DUNCAN. So the total PEPFAR budget is $3.2 billion.

Is there any other country that is contributing figures like that

to fight AIDS outside of their own country that you know of?

Ambassador DYBUL. Tragically, no. According to a recent analysis by the Kaiser Family Foundation, the American people are providing approximately half of all global partner resources for HIV/

AIDS. No one is in the category of the United States. In fact, the

United States provides as much as all other international what is

called donors,a word I really don’t like because we’re talking about

donors/recipients, we’re talking about partners—but yes, we provide as much as everyone else combined.

Mr. DUNCAN. You know, I think that’s very important because I

think some of these are really good things for us to do, but so often

the American taxpayers just don’t get nearly the credit that they

deserve because we’re doing far more in this area than any other

country. No other country, even developed nations, are coming

close. And this money for the most part is being spent in countries

where the cost of medical care is far, far cheaper or far less than

it is in this country; is that correct?

Ambassador DYBUL. Yes, sir. It would be true that the cost per

person for nearly every intervention is lower in the countries in

which we’re working than it would be in the United States.

Mr. DUNCAN. Let me ask you this, a later witness apparently will

testify, or part of his statement says, now PEPFAR and USAID

lead the world in AIDS prevention, promoting a balanced and targeted set of interventions that include abstinence, being faithful

and condoms for those who cannot and will not follow A or B behaviors. This is in spite of formidable and continuing institutional

resistance to change. As a senior USAID officer commented not

long ago, ‘‘USAID is in the condom and contraceptive business, that

is our business.’’

Do either one of you, are you finding this formidable and continuing institutional resistance to change that this later witness refers

to?

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Ambassador DYBUL. Well, sir, let me begin, and then Dr. Hill,

I’m sure, will want to comment on that.

I think one of the important pieces of the GAO report that has

not been commented on often is that in three or four places it

states that there is now a consensus by American government personnel in the field that ABC is a balanced approach as what is

needed. Now that doesn’t mean there aren’t people who are still attached to older philosophies. I actually come to HIV/AIDS as a

therapeutic scientist and researcher, and it’s become very clear, if

you look at prevention data—which I’ve done, I didn’t enter this

with any particular dog in the race, I just wanted to look at the

data as a scientist—that the data for ABC are overwhelming.

There is no example of a decline in HIV prevalence in a generalized

epidemic such as Africa without all three components, without all

three ABC components.

But most of the initial prevention work that was done was not

in generalized epidemics, it was in what’s called concentrated

epidemics, places where identified populations are at high risk,

prostitutes, men having sex with men, truck drivers, and much of

the initial work was done in those populations. And they’re more

of a BC message, which is shown to be highly effective. Unfortunately what’s happened is some people tried to transfer data from

a concentrated epidemic—because that’s the work they were familiar with—to a generalized epidemic, and we still have people holding on to the old data set, not moving to the new data set. But that

is increasingly becoming less and less of an issue as the data are

overwhelming. But we see this unfortunately in any circumstance.

In treatment we still have people who want to use two instead of

three drugs because they haven’t caught up with the data. So we

do have to continually educate and provide the data, and the data

base is growing substantially.

I think we’ve largely overcome some of those earlier prejudices

as the data become available, but it’s a constant effort and we’re

still working on it.

Mr. DUNCAN. Before Dr. Hill comments, let me, before my time

runs out—and maybe Dr. Hill will want to comment on this—that’s

a very good answer, Mr. Ambassador, that you’ve just given me,

but also another later witness will mention the point about where

women do not have the power to refuse unprotected sex and it says

that’s the problem, not the presence of abstinence or faithfulness

per se. Now maybe one or both of you might want to comment

about that, in addition to these other comments or answers.

Ambassador DYBUL. Again, if I could start and then Dr. Hill

could answer both of those two pieces.

You know, in the case of gender equality or violence against

women, negotiating A, B or C is a very difficult endeavor. So as Dr.

Hill mentioned, we need to deal with some of the entrenched gender issues, and we are, in fact, dealing with those. We’re dealing

with those in terms of transactional sex, transgenerational sex,

we’re teaching young men a lot of important lessons about respecting women. We’re tying our programs to issues of gender violence,

including the President’s initiative on women’s empowerment. All

of those are important, but I think it is also important that the

ABC message is relevant for gender inequality; if men learn ABC,

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if men practice ABC, gender issues become easier to deal with because the men themselves will allow for the negotiation of an A,

B or C intervention. We’ve seen over and over again the data for

young men radically changing their B behavior, becoming faithful,

reducing their partners as a major reason for declines in prevalence, and that is very much affecting the gender issue.

So I think as in most things related to HIV/AIDS, any time we

begin with this or that, we’re making a mistake, it’s generally everything and all and more. And so we need all of these approaches

to deal with gender. But ABC is very relevant for gender, particularly if you target the men, and we have a lot of programs to do

that, particularly young men.

Mr. DUNCAN. Plus some of that training for men on teaching respect for women and so forth would help curb this program in the

future. You can’t solve this problem immediately or all at once.

Dr. Hill, I didn’t mean to cut you off. I’d be interested in your

comment.

Dr. HILL. Congressman Duncan, let me begin with your first

question as to whether in fact there is resistance among career people to a comprehensive ABC approach and if there is a favoritism

toward the C.

I think if you talk to career people about this, they will be the

first to acknowledge that the international approach, including

much the of the U.S. approach, in the initial years did tend to view

condoms as a kind of silver bullet that might have a huge impact

on this. But as the evidence begin to mount that condoms were not

going to be enough, and as the evidence mounted as to how prevalence rates were going down in Uganda precisely by using a comprehensive approach, a lot of talk about what they would refer to

as zero grazing or partner reduction or monogamy within marriage,

etc., faithfulness within the sexual partnerships, when the evidence

began to come in that it was this behavior change that was having

a dramatic impact on the lowering of prevalence, career people, it

didn’t matter if they were Democrat or conservative, religious or

non-religious, they could see the facts, they could tell that these

interventions had a lot more potential than they at first perhaps

thought. And so I feel very strongly that the core team of professionals with whom I work with at USAID—and I think this is true

of the other Federal agencies—have really had a remarkable shift

toward understanding the importance of a comprehensive approach. I feel very good about that.

Now, internationally, we have a long ways to go to have won that

battle. And in fact, I really honestly believe that the battle is there.

And Ambassador Dybul is absolutely right to point out that one of

the reasons is so critical that the United States spend sufficient attention on AB is because you’re not likely to find it anywhere else.

It’s not going to be there yet because people don’t yet believe that

it’s going to be that effective.

And so what I really think we’ve got to do is two things. We have

simply got to focus the world’s attention on the fact that this is an

evidence-based approach, that all the data suggests that it can be

very, very effective. What I find fascinating is that even in a place

like Asia where we focused on condoms, AB behaviors changed as

well. The percentages of young men that were having their first

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sexual experience with sex workers or prostitutes went down. The

number of police that were visiting sex workers or prostitutes went

down. Throughout many parts of Africa, the evidence suggested

people could change their behavior, even to the point of changing

to abstinence or to partner reduction if they were sexually experienced. So the evidence is very strong.

The second thing that I think will help get this out of what I call

the culture wars debate is to emphasize the connection to gender

issues. This is a winner of an approach that will affect gender

issues. You cannot affect gender inequality issues or equality issues

without doing AB interventions, they’re critically important to it.

Your last point about—I’m trying to remember what your last

point was—had to do with——

Mr. DUNCAN. It was about the women who——

Dr. HILL. Right. Whether it’s realistic—and I think there have

been two myths that have been perpetrated. One is that abstinence

is not realistic with the young. They simply aren’t capable of it.

Their hormones are too strong. And the second of course is that be

faithful programs don’t work when the husband is not faithful. The

latter point of course is absolutely obvious. That’s why you have to

focus on male behavior and not just female behavior. But the evidence is also overwhelming that young people are quite capable of

moderating their behavior as well.

So I think what’s really needed is for more than ABC, it’s gender

programs, it’s working with pregnant women, it’s treatment programs so that people when they get tested and change their behaviors have some hope for the future. It’s all connected, and we’ve got

to never treat it in an isolated fashion.

Mr. DUNCAN. Thank you, Mr. Chairman.

Mr. SHAYS. Thank you. Mr. Waxman, you have the floor.

Mr. WAXMAN. Thank you, Mr. Chairman.

Ambassador Dybul, there are several countries where overall

prevalence rates have come down significantly. They include Uganda, Kenya and Zimbabwe; is that correct?

Ambassador DYBUL. That is correct, those three; there are many

others, actually.

Mr. WAXMAN. Well, experts have identified multiple reasons for

these declines. Some factors have nothing to do with behavior

change. For example, when young people who have high infection

rates leave the country for economic reasons, average prevalence

goes down; and sadly, prevalence also goes down when death rates

are high. But we do know that in these countries there have been

some positive behavior changes. Can you give us some of the examples?

Ambassador DYBUL. Yes, I’d be glad to. And I think you raise a

very important point about other factors. There’s no question there

are other factors, and this is a very complicated scientific approach.

However, the recent report from Zimbabwe, for example, looked

very specifically at whether or not death contributed to the decline

in prevalence, and they looked very scientifically at that in Science

Magazine. Only 6 percent of the decline in prevalence was due to

death or other factors, only 6 percent. And the report, I mentioned

in my testimony where a group looked across the board at multiple

countries, about 10 actually, they determined that the decline in

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prevalence was in fact substantial behavior change. While these

other things contributed, it was substantial behavior change.

A couple of the examples that we can give, whether it’s Uganda,

Kenya or Zimbabwe, which probably have the most up to date solid

data in this respect—we’re still looking at some of the other countries—as I mentioned, 50 percent decline in young men who had

multiple partnerships. Increase in age of first sexual activity by a

year or so, and in fact this overall survey determined that, as in

Uganda, was probably one of the most substantial reasons why we

saw a decline in prevalence because just that shift in a year remarkably shifts the epidemiology of the infection as less people become infected early who then infect less people. That’s a very significant impact.

Importantly, secondary abstinence, building on what Dr. Hill just

said, Kenya actually looked in their demographic health survey at

people who had previously been sexually active versus those who

had been sexually active in the last year; secondary abstinence,

people who have been active sexually and no longer were, and saw

remarkable progress there, 50 percent.

We also saw, both in the Zimbabwe data and in the Kenya data,

as in the Uganda data, some increase in condom use particularly

among young women, now a doubling of the use of condom use

among young women. Unfortunately we didn’t quite see a commensurate change among the young men.

So it is a complex picture, but the data are repeated over and

over again supporting A, B and C.

Mr. WAXMAN. My understanding of the epidemiology is that we

can link these behavior changes to lower prevalence rates, but

what we generally can’t do is say this program led to that behavior

change, resulting in lower prevalence. Can you explain that?

Ambassador DYBUL. Yes, and this gets to the complicated nature

of behavioral science. Aristotle once said you can only be as precise

as your subject matter allows, and unfortunately that is the case

with behavioral science. Unlike treatment, where you can follow

someone’s CD–4 cell count or follow their viral load, behavior signs

is a much different thing. So what we do is look at prevalence

rates, as we’ve talked about, and we look at behavior change that

has occurred over that same time period. You can then link and

say this program led to this effect. You can look to see where programs were introduced and whether or not they were introduced

largely, and whether or not—you can basically guesstimate that

those programs in fact led to the change in behavior that was correlated with the decline in prevalence. It’s a much more complicated matter than most sciences.

Mr. WAXMAN. I think that’s an important point to highlight because there’s a tendency to get bogged down in arguments over exactly which kind of program got results at a national level, but we

can’t make that kind of claim. We can only know that in certain

countries that did implement comprehensive programs, significant

behavior changes have led to decreased prevalence. While it’s important to clarify the limits of our current knowledge, we do need

to get more precise information on how specific interventions impact behavioral change. What are we doing to study this?

42

Ambassador DYBUL. And that’s an important point because that

is something you can do in a scientific way is look at programs and

see what impact they’ve had on behavior change. We actually do

this in a variety of ways. Many partners do it themselves, and in

fact we just had a meeting in Durban, South Africa where 700 scientific abstracts were presented, including quite a few on this topic,

where, for example, in Nigeria they introduced what’s called the

zip-up campaign, and during the time that the zip-up campaign—

which was an abstinence campaign—was in play, they saw a dramatic increase in abstinence activities. We have looked at programs

on college campuses where we’ve introduced such ABC programs

and looked at the change among those participants.

We have done a number of what we call targeted evaluations to

look at this approach. These take a long time. They generally take

a couple of years. Dr. Hill talked about a couple that USAID is

doing. We’re also shifting the way we’re doing things, moving from

a targeted evaluation approach to public health evaluation approach so that we can do more and more of these efforts, and they

are ongoing——

Mr. WAXMAN. Ambassador Dybul, I have a lot of other questions,

but I appreciate your answer to that. And I think these evaluations

are extremely important. I also think that country teams should

have the flexibility to refine their prevention programs based on

the evidence we glean from these studies in the coming years.

Your office has turned the one-third requirement into two parts;

countries must spend at least 50 percent of prevention funds on

sexual transmission; then they must spend 66 percent of those

funds on AB programs. I understand that a number of countries

were able to get exemption from one or both of these requirements;

isn’t that correct?

Ambassador DYBUL. That’s correct.

Mr. WAXMAN. Now for the countries that didn’t get exemptions,

the formula means that if they spend more than 50 percent on sexual transmission, they must spend more than 33 percent on AB

programs; is that right?

Ambassador DYBUL. That’s correct. And that makes some sense.

I’d be happy to explain that.

Mr. WAXMAN. In response to the GAO report, the administration

said that—you asked those countries that didn’t apply for exemptions if they wanted to, and you wrote that the answer was a resounding no. I’d like to read into the record what U.S. guidance is

to these countries.

Both in 2006 and 2007 guidance state, ‘‘please note that in a generalized epidemic a very strong justification is required to not meet

the 66 percent AB requirement.’’ The 2006 guidance also said, ‘‘we

expect that all focus countries, and in particular those with budgets

that exceed $75 million, will meet these requirements.’’

In addition, both years guidance state, ‘‘in any case, no country

should decrease from 1 year to the next the percent of sexual transmission activities that are AB. There will be no exceptions to this

requirement.’’

I think that it’s difficult to know what country would really have

deferred, absent this strong language from their biggest donor.

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Ambassador Dybul, I’d like to ask you a few questions about

male circumcisions. I understand that four of these studies have indicated male circumcision decreases the risk of a man contracting

HIV, and one randomized control study showed that male circumcision lowered the risk by about 75 percent. Lower rates of HIV

among men will mean fewer risks for women in the population.

Can you tell us what the United States is doing to assess the appropriate role of male circumcision in HIV prevention?

Ambassador DYBUL. I’d be happy to. I’d first like to get back to

some of the difficult issues you raised with behavioral data.

Mr. WAXMAN. Excuse me, Ambassador Dybul. My problem is that

in another second or two the light is going to switch, so I really

do have to move on.

Ambassador DYBUL. I would just say in a sentence that most of

those studies——

Mr. WAXMAN. The chairman said I can have as much time as I

want, so please feel free to go back. And we’ll stay here all day.

Mr. SHAYS. No. The bottom line is that we don’t have a lot of

members, but if Mr. Waxman wants you to answer another question, he has the privilege to ask you to go to the next one.

Ambassador DYBUL. Most of those studies just showed an association between people who were circumcised and the protection.

There are now a couple of studies that were just presented in Toronto that showed that in fact isn’t holding up. That one randomized control target you mentioned looked at the actual intervention;

programmatically if we proactively did circumcision, would there be

a benefit. One trial has shown a benefit, a 60 to 70 percent reduction to men, it said nothing about the women. It also showed an

increase in sexual activity by the young men, and there’s actually

a mathematical model that shows if men think they’re fully protected and have more activity, you can actually offset the benefit

of the circumcision.

Mr. WAXMAN. Let’s take that first part. If men don’t get HIV because they’re circumcised, it does help the women because if they

do have sexual activity——

Ambassador DYBUL. The problem is that they do, they just get

a lower rate. It’s a 60 to 70 percent reduction. So that’s why you

can actually mathematically show that if men increase their activity by a certain percent it will offset the benefit of the circumcision.

We don’t know that. That’s a guesstimate.

There are two other randomized controlled trials, large trials

that are underway right now, they’re ongoing. The Data Safety

Monitoring Board has twice not stopped the studies; in other

words, allowed them to continue. We don’t know what that means.

We are expecting data in the next 6 to 12 months, depending on

whether they get to their end points.

These studies look a little more carefully at some of the other

issues involved. In anticipation of those studies, because we don’t

know the results and it would not be responsible, no one in the

world right now is advocating—no major international organizations are advocating active programmatic use of circumcision, but

what we have done is given countries flexibility—and several have

through our resources—to do preliminary work, to do preparatory

work. Unfortunately, as you know, circumcision does have cultural

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connotations to many people, and so we’re doing some of the cultural sensitivity work, just like we have to do for vaccines and

other work. Should circumcision be proven to be effective and have

normative guidance, one implementing agency, not a scientific

agency, that’s NIH and other people’s business, should there be

normative guidance on the use of circumcision, it is something we

would fund, but we will do it carefully because you need to provide

the ongoing ABC behavior change with the circumcision or you can

actually offset the benefit.

Mr. WAXMAN. I appreciate that answer. I certainly hope—and

we’re going to have to look at the evidence—that this can help in

reducing HIV transmission. I also hope that if and when the time

is right program staff will have the funding and flexibility to implement it, and I see you shaking your head.

Mr. Hill, I’d like to ask you about the role that the one-third earmark has played in the policy. There are some who say before the

President’s program started there was too much emphasis on

condoms. And I gather that was your view as you expressed it earlier; is that correct?

Dr. HILL. I think that’s what my career folks tell me; they tell

me that there was a tendency to focus on condoms, yes.

Mr. WAXMAN. And do you think things have changed since

PEPFAR started?

Dr. HILL. Yes. Both because of the evidence, because we were

forced to look at the evidence closely. So no, I think it’s quite a different situation now. The best empirical studies on this are given

by career people, not by political appointees.

Mr. WAXMAN. If the legislative earmark were to be removed or

modified, would USAID and its partner agencies still work to ensure that abstinence and be faithful programs play an appropriate

role in country’s HIV prevention programs?

Dr. HILL. I’d like to think we would. As an implementer, you

know that all implementers like flexibility, they like the options of

making their own decisions on how to do things. But I do think it’s

appropriate and right for Congress to insist that we have a comprehensive strategy, but I’d like to believe we would do the right

thing anyway.

Mr. WAXMAN. Well, Dr. Dybul’s office has the authority to approve or reject a country team’s plans each year, and I trust that

if the arbitrary quota for abstinence programs is removed, you

both, along with our health experts in the field, would maintain AB

programming where it is supported by evidence and by local needs.

Ambassador Dybul, you noted in your testimony the U.S. continues to support condoms and condoms programs. While many believe that we are not doing enough to promote and fund condom

use, you clearly agree that condoms are a crucial component of an

effective prevention program.

I have a question about appropriations language that has been

referred to as the condom nondisparagement provision. It says, ‘‘information provided about the use of condoms as part of projects or

activities that are funded from amounts appropriated by this act

shall be medically accurate and shall include the public health benefits and failure rates of such use.’’

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Well when used consistently and correctly, condoms reduce HIV

transmission by 85 percent to 95 percent. But there have been disturbing reports of programs that teach that condoms have holes or

that they don’t block HIV.

What is the administration doing to ensure that U.S.-funded programs do not spread false information about condoms?

Ambassador DYBUL. Thank you for that question because it is an

important one. Because we do have a full ABC approach as is evidenced by our funding distribution and by our guidance. We would

take that provision of the law as seriously as any other provision.

And so we make clear to everyone, and have done so on multiple

occasions, that should anyone be aware of such activity occurring,

such medical misinformation occurring, in a PEPFAR-funded program, we need to know about that, and we need to intervene either

at the level of the cognizant technical officer and, if that is not successful, higher than that.

Dr. HILL. There is actually in the USAID contract, for example,

a very specific provision which requires any recipient of funds, even

if all they are doing is AB programming, if they mention C, they

have to mention it in a medically accurate way. If a report reaches

us that they are not, that is a breach of what they signed.

Mr. WAXMAN. I appreciate that answer.

Thank you, Mr. Chairman.

Mr. SHAYS. In answer to almost every question, there was the

word ‘‘evidence.’’ And I am not quite sure how to take the word

‘‘evidence.’’ I am more inclined to want to say there are indications

that. What scientific evidence is available that says that one-third

should be for abstinence as opposed to two-thirds or as opposed to

one-sixth? Why one-third?

Ambassador DYBUL. Well, there is certainly no randomized controlled clinical trial that gives a percent of a program that should

be dedicated to one or the other. What we do have are data that

suggests very clearly that you need all three components, A, B and

C, and 33 percent gives us a very balanced program.

So you can’t find a randomized controlled trial to give you that

number, but you can find an interpretation or application of available data for a balanced approach that would get you to 33 percent

for AB.

Mr. SHAYS. Dr. Hill, how would you answer the question?

Dr. HILL. Well, I think the experience of PEPFAR in practice illustrates that, in fact, it is not viewed as rigid. There has been

enough flexibility, Congress has allowed enough flexibility, that

when it was appropriate to not spend that amount, exceptions have

been made. In some cases it would be appropriate to have a higher

percentage.

So, in fact, the way the program has been implemented shows a

fair amount of flexibility.

Mr. SHAYS. When would it make sense to have it higher than

one-third?

Dr. HILL. If it was a generalized epidemic, it is very possible that

the messages to the general public that have to do with behavior

and the behavior of young people and the behavior of sexually active people could have the biggest impact on lowering the prevalence rate. If it is not primarily being spread by truck drivers or

46

by sex workers or prostitutes or in the high-risk groups, that it is

a very good possibility the behavior change messages in AB are the

things that will likely bring the prevalence rates down the fastest.

Ambassador DYBUL. In addition to that, Mr. Chairman, if I could

add, again, we are not the only player. While we are as much as

everyone else in the world combined, there are others. And so we

ask our country teams to look at the circumstance in their country,

getting to the comment by the Minister of Health in Namibia that

he needs us, the United States, to provide substantial support for

AB because no one else is doing it.

Mr. SHAYS. Briefly describe three or four abstinence programs to

me.

Ambassador DYBUL. I can describe some of the ones I have seen.

I can give you a couple from different age groups, and, again, we

have very few abstinence-only programs except for young kids.

What we have are AB programs and ABC programs once you got

above 15. So an example of an A only program would be a 10-yearold school program where for 10-year-olds in schools, the teachers

have sessions on a daily basis. And this is a program in Uganda

where the kids in the morning learn about the importance of HIVAIDS in their community and how they as a 10-year-old can avoid

it through abstinence.

As you get older, the message changes to AB messages. So we

have programs in older kids, but still under 14, where they talk

about the importance of HIV-AIDS in the community, but also abstinence and fidelity overall. And this is in the school.

Mr. SHAYS. So abstinence and fidelity in what terms?

Ambassador DYBUL. People use different terms, and, again, it is

culturally sensitive. In many countries being faithful means go to

church. So they use different terms such as zero grazing. In some

countries the term abstinence doesn’t resonate——

Mr. SHAYS. I can see you explaining to someone that maybe they

don’t want to smoke because they will get cancer. That would have

a huge impact.

Ambassador DYBUL. Absolutely. And that is——

Mr. SHAYS. But it is more than just explaining that abstinence

will protect you from getting HIV-AIDS. It is into more than just

that, correct?

Ambassador DYBUL. If I understand the question correctly, it begins with the danger, the risk to you for HIV-AIDS.

Mr. SHAYS. Let me say it this way: I think being honest with

people is essentially important. Being able to tell someone that if

they don’t protect themselves, they will get—and are involved in

sexual activities, the risk is very high they will get HIV-AIDS.

That seems like an honest thing to tell people. It seems like an

honest thing to tell people that a lot of people are dying because

of it. Those—if that is an abstinence program, it seems pretty logical.

If you get into issues about, you know, about lifestyles, and how

you might go to hell because you are not abstaining, and you are

choosing the wrong direction, then I am just wondering about that.

And is that part of the program?

Ambassador DYBUL. Our program is based in public health and

in public health evidence, and different people come to that from

47

different perspectives. The majority of, vast majority of, our programs—in fact, all the ones I have ever seen—begin with what you

began with, which is that HIV-AIDS is a risk to you, and you need

to protect yourselves so that you can live a healthy, productive life,

and that is where most of them begin, nearly all of them begin.

Mr. SHAYS. Do you have the scientific evidence to know which

kind of abstinence program works better? Because I keep hearing

the word ‘‘evidence.’’ I will tell you this: If you told me I would get

AIDS, that gives me religion real quick.

Ambassador DYBUL. Well, it might, but unfortunately that is not

always the case. Some of the most disturbing data I have seen are

that children who are orphaned from AIDS, they watched both of

their parents die from AIDS—they know they died from AIDS—

still don’t necessarily practice safe sex, still don’t abstain, be faithful, or correct and consistent condom use. So even that immediate

experience did not alter their behavior.

On the other hand, I think there is general agreement that the

data are not particularly good on this, but the fear of death has

driven behavior change, whether it be in this country or in Africa,

and perhaps one of the reasons we are starting to see an uptick in

infection rates in this country and in Europe and in some parts of

Africa might be fatigue with that message, that you hear it so

many times, you don’t respond to it. And there are some data on

that as well.

So the problem with behavior change is it is a long-term thing.

If you keep telling the people the same thing for 5 years, eventually it is going to go over their heads. And that is why behavior

change is so difficult, why behavior medicine, why behavior science

is so difficult, because it is finding messages that link to and lead

to changes in behavior.

And that is fundamentally what we do, culturally appropriate

messages that resonate with people, which is why Nigerians talked

about zip up and Ugandans talk about zero grazing. People look at

what will be the best message. Sometimes that message is within

your cultural context, within your religious context, in addition to

the HIV-AIDS practices and the effect of HIV-AIDS within your

culture, there are other reasons that you should practice safe sex.

Sometimes it is because of the tribal system. One of our most effective is Massai warriors. Massai warriors become warriors when

13 or 14, I can’t remember which. They are collected together as

young men and are taught to go out and abuse women. Well, the

program we intervened with was to teach them that it is actually

manly to actually becoming a warrior to refrain and to respect

women; that is, in fact, a manly action within that tribal tradition.

So you have to find the right messages which will lead to behavior change. The Minister of Health——

Mr. SHAYS. Let me comment on that last point.

I have no problem with the logic of what you just said. I have

a problem with saying that one-third goes toward this program.

And, you know, what I am hearing, being very candid with each

other, basically what I believe is that when we appropriated the

dollars, frankly, it was—one way to get it done was to win over

some who don’t want condoms as—their dollars being spent on

condoms so that they then say, at least I can justify that we are

48

spreading the word of God to folks through abstinence and so on

and feel comfortable. And what I then feel is that both of you have

to step up to the plate and justify why we have done that.

And so when I hear the word ‘‘evidence,’’ I have a hard time

knowing the definition of evidence, but the program you just described, teaching a different behavior, I think there is logic to that.

But there is no logic to me that says, that one-third should go that

way.

Dr. Hill, as well, would you be able to just tell me some more

examples of abstinence programs?

Dr. HILL. Yes. The point I alluded to in my oral comments about

Soul City in South Africa is probably one of the best I have heard

about recently. They produced a whole series of films that were

shown on prime-time television which all address different values,

different responsible behavior, etc. It wasn’t heavy hitting, always

talking about HIV, but it set the context for how men should treat

women, etc.

And the initial evidence of this suggests that people are reconsidering behavior that, in fact, is problematic, that leads to the spread

of HIV-AIDS. That’s a good example of a very sophisticated behavior change program using medium.

But if I might, I would like to just address this question of what

reasons we give——

Mr. SHAYS. I will give you a chance. I want to know more programs. So if either one of you want to tell me others.

Dr. HILL. Other examples? A lot of what we do in countries is

that we will fund youth clubs, so after-school activities where kids

get together anyway to do sports or just get together to get help

with respect to certain things, we find ways; we have implementers

that will introduce topics that will bring up sexual conduct, etc.

They can ask questions. We try to be age appropriate, etc. I met

with some of these groups, had discussions with these kids, and

there is every reason to believe that kind of discussion can be useful. And there is a lot of countries in which we fund those kind of

youth clubs.

Ambassador DYBUL. A specific example of that would be in

Kenya. I just visited a program where college kids became concerned about the pressures, the peer pressures. College kids themselves were concerned about the pressures that they saw themselves and their classmates under to engage in sexual activity.

They conducted a survey which showed that only 20 percent of the

entering freshman had engaged in sexual activity in college, but 80

percent thought that their friends had. So you can see kind of the

peer pressure and the disconnect between what people are actually

doing and what they thought was going on.

As a result of that, they put together a program that we are supporting to teach people that it is OK, in fact it is a good thing, both

for public health and your own self-worth and respecting yourself,

to remain abstinent, or, if you had been sexually active, to become

abstinent. And these are the students themselves that put this program together.

Dr. HILL. And these programs are called life skills programs in

which they will set up drama, set up scenarios in which a young

person might encounter, for example, an older man, some other

49

generation offering a girl tuition or books or something in exchange

for sexual services. This explains or this shows them, demonstrates

for them, how they could say no, why they should say no.

It addresses other questions where they are being coerced: How

do you say no? How do you make sure that what you want is respected? You have to model that, and we often do that through

drama.

Ambassador DYBUL. Another example of these types of programs

which I think are important ones and get missed are ones that target men specifically. There are actually programs in Namibia that

say sometimes stigma is a good thing to stigmatize older men who

prey on younger women.

Mr. SHAYS. We call them, what, sugar daddies.

Ambassador DYBUL. Exactly. So to stigmatize them, basically

drive men out of the community who engage in and who participate

in such activity, that is an ABC program.

In a similar way the program Dr. Hill mentioned in South Africa,

a wonderful young man started on his own when he was 14 or 15,

his father was an alcoholic, and he drew on the program because

he saw the same thing, that his friends were abusing women. He

started the program to go around from his own personal experience

to explain why young men shouldn’t behave that way toward

women, why young men should respect women, why they are equal

to each other, why you would have a healthier life as you move forward, and it has grown into now he is a national representative for

a national program to target young men to teach them to respect

women in an ABC way and to give ABC messages. So——

Mr. SHAYS. Finish your sentence.

What did you want to say, Dr. Hill, when I wanted to——

Dr. HILL. I think you were onto something when you were probing the question of about sort of what are acceptable reasons to

sort of pursue a behavior change. And there is this fear out there,

I have heard it a lot internationally, I have heard it sometimes in

this country, if it can be demonstrated that somebody used a moral

argument for behavior change, that somehow we may be dangerously close to crossing some line that USG dollars should not be

spent for. And I just want to suggest that I think as important the

health reasons are, it would be counterproductive to misunderstand

that human beings are far more than just material creatures. They

don’t just respond to motivations that have to do with their appetites. They often respond to motivations that have to do with doing

the right thing, whether it is treating another person with respect.

They get nothing out of it, they certainly don’t get sex out of it, and

yet people, young people, repeatedly demonstrate that they can respond to stimuli which says, you know, be a man, do something

that shows that you are more than just an animal that is going to

follow your sexual urges.

One of the reasons that we like to work with faith-based groups

is that they often approach people at that deeper level. And you

can sometimes get young people to respond to moral pushing and

prodding as easily or more easily and with more passion than just

the health issues.

So I think the tent has to be big enough to include people making all sorts of arguments. We tell the faith-based folks, use health

50

arguments as well. And I tell the folks who just want to use faith

arguments, be sensitive to your culture. And if these folks are from

a Muslim culture or an orthodox culture or whatever the culture

is, if there is something there which stresses monogamy or faithfulness or not lying, for goodness sakes use those arguments as well.

We he have to stop the spread of HIV.

Mr. SHAYS. I have absolutely no problem with there being an abstinence problem. I have a problem with stating that it needs to

be one-third. That is my problem, and because some places maybe

it should be two-thirds. I don’t know.

I doubt it. But I would think—and part of it, admittedly it is not

based on a wide experience, but when I was in Tanzania and Uganda to hear people describe using condoms more than once because

then they weren’t available is pretty gross. To hear people describe

having sex without condoms because they couldn’t get it was pretty

gross. To see people waiting in clinics to learn if they had HIVAIDS—and I will tell you, it was—there were hundreds in every

place we went, and we got to interview them. And we got to ask

them—you know, here I am thinking they are waiting to learn if

they are going to die. They are willing to answer questions about

whatever I wanted to ask them.

And what I was struck with was it would be an absolute outrage

if someone could have had a condom and didn’t, but somehow they

weren’t available because we were diverting money in a different

direction.

If you had a choice of teaching someone abstinence, and they

weren’t going to abstain, is it better that we did that, or is it better

that we make sure that they have a condom?

Dr. HILL. It is why you made a great case for a comprehensive

approach. You can’t do any of these interventions alone. There is

a place for A. There is a place for B. There is a place for C.

Mr. SHAYS. Let’s agree with that, provided that the other two get

what they need before abstinence gets what it needs.

Dr. HILL. If you look at the statistics on condoms over the last

8 or 10 years, during the PEPFAR years we provided more

condoms than in the previous years. So it is not that condoms are

actually going down in terms of the number that we are providing.

That is a robust and major part of our prevention. So we are not

arguing that it should go down. It should be a big part of what we

do.

It also should be the case, and, as you know, it is not abstinence

that is one-third, it is allowed to be interpreted as AB. And that

is a very important part of the message, just as C is.

Ambassador DYBUL. If I could build on what Dr. Hill said, we,

in fact, have had substantial increase in support for condoms under

the emergency plan, 130 percent increase, and 110 percent increase

for AB. So we have had substantial increases across the board for

A, B and C.

Unfortunately it is not enough. We cannot, with the resources of

the American people, cover everything, which is why we need the

rest of the world to be doing a lot more they are doing.

Mr. SHAYS. That we agree, but what I think I heard you say is

that some people are not getting condoms because we simply can’t

provide them.

51

Ambassador DYBUL. And some people aren’t getting AB messages

yet because we can’t them get to them. And some people are not

getting PMTCT because we don’t have——

Mr. SHAYS. So what comes first?

Ambassador DYBUL. What comes first is what makes you avoid

infection, which is A and B and, if you can’t do that, C.

Mr. SHAYS. What happens if you are trying to convince someone

to abstain, but, guess what, they are going to have sex? Because

as much as you both may not want them to for their own good,

they are still going to do it.

Ambassador DYBUL. And that is precisely why when you are

above the age of 14 the message is an ABC message. It is not one

or the other. It is the public health information to allow people to

have a choice. It is giving them the information that abstinence or

fidelity to an HIV-negative partner is a 100 percent way to avoid

HIV infection, and there may be tribal and other messages that

come into play with that. But if that isn’t possible, if someone

doesn’t choose to do that, they have the information available

through some vehicle that condoms will protect them. But we can’t

cover everything because we don’t have the money.

Mr. SHAYS. Let me ask you, if countries were allowed to decide

for themselves whether to put one-third toward abstinence, would

countries still decide to do it, or would they choose not to?

Ambassador DYBUL. I have little doubt that they would.

Mr. SHAYS. Would what?

Ambassador DYBUL. Would support full ABC and put considerable resources toward AB, or more.

Mr. SHAYS. Why require it?

Ambassador DYBUL. Because it is coming from the U.S. Government and not from those countries. If you look at the national

strategies——

Mr. SHAYS. That is the problem I have. If your answer to us is

that they prove their worth to these countries, why do we just

have—why do—in the only area why do we set aside one-third for

abstinence?

Ambassador DYBUL. It is actually not the only area. There are

a number of congressional directives for other resource requirements of the emergency plan besides the 33 percent. There is treatment, there is orphans and vulnerable children, there are other directives. The national strategies of virtually every country in Africa

where they have them lists ABC as their approach, not C. ABC.

The Minister of Health of Namibia was very clear in his response

in the Lancet report saying, I need the American people to be doing

heavy AB because no one else is doing it. We get C from other

folks. We don’t get AB from anyone else. We need a direction that

allows us to provide the full balanced message, not a single message.

Mr. SHAYS. You kind of turned my question on end. I wasn’t saying you would limit it. I would say if they want to spend two-thirds

they could spend two-thirds. So I don’t really think you were answering the question. The question was, why require it? And your

answer, I guess, in the end is not based on science; based on the

fact that Congress has required it, that is why we have it.

52

You have done a very good job—I am interrupting you but you

have done a very job of putting the best case forward I think you

can do. But it still doesn’t answer the question why it is one-third.

Ambassador DYBUL. I think you are right. Maybe it should be

more than a third. I don’t know, but the law is at least a third if

not——

Mr. SHAYS. I never said it should be nothing. I am saying if a

country wants to spend more, that it could spend more. We are

going to hear from other people in the second panel, but in my brief

visit to Uganda and Tanzania, it was—I was struck by this fact.

I was struck by the fact that when I spoke to college kids, they

were telling me if they don’t have condoms, they are still going to

have sex, and so are their friends. That is what they said.

And what they said is kids back in villages are still going to have

sex no matter what you think about—however, you know, effective

your abstinence programs are, they are still going to have sex. So

you can decide to let them have sex without condoms, or you can

let them decide to have sex with condoms. They are still going to

have sex.

Ambassador DYBUL. Mr. Chairman, I think it gets back to your

point on evidence. The evidence is that people are changing their

behavior. The evidence is that we are seeing a reduction in partnerships and sexual activity.

Mr. SHAYS. But the evidence is not clear if they are changing

their behavior because we have an abstinence program that tells

them the truth, by the way, you may get AIDS, or we have an abstinence program because it is better for your soul and you will

grow up to be a better person. We don’t have evidence as to what,

why and which programs work.

Ambassador DYBUL. I think that is true, and I have stated that

we don’t know that yet. We do have some data on some programs;

for example, the Zip Up Program in Nigeria. We do have data from

some other programs, Soul City and a few others, and we are still

working on those.

The fact of the matter is that we need to have a broad-scale ABC

message to everyone in every place that condoms should be available to all those who need them. But the issue of priority of just

providing condoms without AB we know is wrong, too.

Unfortunately, and again this gets somewhat to the President’s

request, were the President’s request met for the focused countries,

we could increase AB and C. Would the rest of the world step up

to its responsibility to match the United States, we could do

enough AB and C.

I don’t think it has to do with the lack of availability of condoms

to college kids any more than it has to do with lack of AB messages. It is a problem of resources and the rest coming from the

rest of the world and the President’s full budget being supported.

But we have increased AB and C. We would like to increase it

more, and we will increase all three of those more with additional

resources.

Mr. SHAYS. Is there any other comments you want to make before we get to the next panel? Is there anything we need to put on

the record?

53

Dr. HILL. I think I would just add that one way or another,

whether it is by congressional directive of some sort which instructs us to make sure that we do a comprehensive approach—because the basic message of ABC is critically important, it is going

to vary little from country to country—one way or another, whether

that prodding comes from you or comes from the Office of Global

AIDS Coordinator or from central authorities in Washington, it is

like any other guidance. It is given because you want to ensure

that you get a balanced program that does as much as possible.

Having some flexibility is fine, but we have to make sure that we

push hard on this because, in fact, in the past it wasn’t a balanced

program, and this was an effort to try to make it more balanced.

Mr. SHAYS. You wanted to say something?

Ambassador DYBUL. I would say I think this has been a very important hearing. I would just want to state that the American people through PEPFAR are supporting the broadest comprehensive

HIV-AIDS prevention strategy in the world beyond question.

I think we may do all of ourselves a disservice by concentrating

too much on various percents when we know ABC is the proper

message, and stick to supporting things and expanding programs

and having that comprehensive base shifting as we go, should male

circumcision, microbicides or other things become more available,

but sticking to the basic sense that ABC is the foundation. Gender

is something we need to deal with, alcohol, all of the things we are

supporting, and try to focus more on what we can do going forward

rather than focusing too much on a percent that isn’t radically affecting things in the field in a negative way at all and, in fact, had

some very positive——

Mr. SHAYS. Let me put on the record my own view that you both

are very dedicated people. You are taking a law that has been

passed by Congress, and you are seeking to implement it. I know

this is a morning, noon and night effort on your part and the people that work with you.

I happen to be a very proud American of what we have done, and

I know the President is criticized for a lot of things, some of which

I have been, you know, out there criticizing him for. But I am very

proud of our country’s focus on this issue. As a former Peace Corps

volunteer, I know that we are doing so much more than any other

country, and so while we are asking you these questions, and we

might have some disagreements, we don’t have any disagreements

over the importance of this issue and the dedication of your people,

and we do appreciate your being here.

I do want to recognize Barbara Lee. We are going to get on to

our next panel, but I would just note that she has unanimous consent to participate in these hearings, and she is a real leader on

this issue. Maybe you would like to just address these two gentlemen before they get on their way, and if you would like——

Ms. LEE. Let me just first thank you. Forgive me for being late.

I will definitely, though, review testimony, and appreciate everything that you are doing. And, Mr. Chairman, I just thank you for

giving me the opportunity to sit in on this very important hearing.

As you know, I helped write the PEPFAR legislation, and we

want it to work. And I think today’s hearing will let us know if it

is working, if it is not working, what the abstinence-only policies

54

mean in the field, and what to do about them if they are not working.

And I thank you very much, Mr. Chairman.

[The prepared statement of Hon. Barbara Lee follows:]

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56

57

Mr. SHAYS. Thank you.

Gentlemen, thank you both so very much. Appreciate your being

here.

Mr. SHAYS. We will ask the next panel to come in just 1 minute.

Our next panel is Dr. David Gootnick, Director, International Affairs and Trade, U.S. Government Accountability Office; Dr. Helene

Gayle, president, chief executive officer, CARE USA; and Dr. Lucy

Nkya, member of Tanzania Parliament, medical chairperson, Medical Board of St. Mary’s Hospital, director, Faraja Trust Fund, to

which I have denoted $100 since she shook me up for it; and Dr.

Edward C. Green, senior research scientist, Harvard Center for

Population and Development Studies, director, AIDS prevention

and research project at Harvard University.

Now that you have sat down, Dr. Gootnick, we are going to ask

you to rise and—we will ask you to rise, and we will swear you all

in.

[Witnesses sworn.]

Mr. SHAYS. What we do is we swear in all our witnesses. You can

swear or affirm, but raise your right hands.

In 10 years as a chairperson, there is only one person we have

never sworn in, and that was the good Senator in West Virginia.

I chickened out, Dr. Green, I just couldn’t do it.

We will start with you, Dr. Gootnick, and then we will go to you,

Dr. Gayle.

Welcome. Let me explain, we didn’t do too good a job last time,

but we have a green light there on both ends. We leave them on

for 5 minutes, and then we allow you another 5 minutes if you

need it. But we have four on the panel, so it would be good not to

go beyond the 10 minutes. I will interrupt you after that certainly.

So welcome.

STATEMENTS OF DAVID GOOTNICK, DIRECTOR, INTERNATIONAL AFFAIRS AND TRADE, GOVERNMENT ACCOUNTABILITY OFFICE; HELENE GAYLE, PRESIDENT AND CHIEF

EXECUTIVE OFFICER, CARE USA; LUCY SAWERE NKYA, MEMBER OF TANZANIAN PARLIAMENT (MP, WOMEN SPECIAL

SEATS), MEDICAL CHAIRPERSON, MEDICAL BOARD OF ST.

MARY’S HOSPITAL MOROGORO, DIRECTOR, FARAJA TRUST

FUND; AND EDWARD C. GREEN, SENIOR RESEARCH SCIENTIST, HARVARD CENTER FOR POPULATION AND DEVELOPMENT STUDIES

STATEMENT OF DAVID GOOTNICK

Dr. GOOTNICK. Thank you, Mr. Chairman. Mr. Chairman, Congresswoman Lee, members of the subcommittee, thank you for the

opportunity to discuss GAO’s recent report on prevention funding

under PEPFAR.

As you know, the May 2003 leadership authorized PEPFAR; established the Office of the Global AIDS Coordinator, or OGAC; and

established the GHAI account as the primary funding source for

PEPFAR. The act also endorsed the ABC approach, recommended

that 20 percent of the funds under the act support prevention, and

requires starting in fiscal 2006 that one-third of prevention funds

be spent on activities promoting abstinence until marriage.

58

Our report reviews PEPFAR prevention funding, describes

PEPFAR strategy to prevent sexual transmission of HIV, and examines key challenges associated with the strategy. In addition to

document review and analysis, we present the results of structured

reviews with key U.S. officials or country teams in each of the focus

countries who are responsible for implementing PEPFAR programs.

Regarding our findings, PEPFAR prevention funding in the focused countries rose by more than 55 percent between fiscal 2004

and 2006, increasing from roughly $207 to $322 million. I note that

our figures differ somewhat from those presented by Ambassador

Dybul and would be happy to discuss that in the Q and A.

During this time the prevention share of focused country funding

fell by about one-third, bringing it into alignment with the act’s

recommendation that 20 percent of PEPFAR funds support prevention.

The PEPFAR preventing strategy for preventing sexual transmission is largely shaped by the ABC approach, Congress’s onethird abstinence-until-marriage spending requirement, and local

prevention need. OGAC adopted broad principles associated with

the ABC model.

Mr. SHAYS. Doctor, why don’t we move the mic a little to the left

because you pronounce Ps very well.

Dr. GOOTNICK. OGAC adopted broad principles associated with

the ABC model, directing country teams to employ best practices

coordinated with national strategies and focused countries, integrate across A, B and C activities, and be responsive to the key

drives of the epidemic and local cultural norms in each country.

To meet the spending requirement for fiscal 2006, OGAC directed

that each focus country team, amongst other things, direct at least

half of their prevention funds to the prevention of sexual transmission and within that spend $2 on AB programs for every dollar

spent on what OGAC refers to as condoms and related prevention

activities. Of note, activities that support IV drug, alcohol reduction

and others are considered under condoms and related prevention

activities. Seven focus country teams, primarily those with smaller

PEPFAR budgets, received exemptions from this requirement.

Regarding key challenges, although several teams noted the importance of promoting abstinence, more than half of the focus country teams reported that the spending requirement limited their

ability to design prevention programs that were integrated across

A,B and C, and most teams reported that fulfilling the spending requirement challenged their ability to respond to the local conditions

and social norms in their countries.

Between fiscal 2005 and 2006, funding in the focus countries for

abstinence-until-marriage programs rose from $76 to $108 million.

During the same interval, condoms and related activities and prevention of mother-to-child transmission programs in these countries had roughly level funding. These program shifts allowed

OGAC to project that it will meet Congress’s one-third abstinenceuntil-marriage spending requirement. However, to meet the requirement for fiscal 2006, seven countries planned declines in

PMTCT funding that ranged from roughly 5 to over 60 percent and

seven projected cuts to programs aimed primarily at high-risk acVerDate 11-MAY-2000 10:03 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6633 C:\DOCS\35621.TXT HGOVREF1 PsN: HGOVREF1
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tivities in vulnerable populations. These cuts ranged from 7 to over

40 percent.

Finally, as a matter of policy, OGAC also applied the spending

requirement to certain USAID and HHS funds despite its determination that by law the requirement applies only to funds appropriated to the GHAI account. These non-GHAI funds are a small

part of the focus country prevention budgets; however, they represent more than 80 percent of U.S. prevention dollars for five additional countries, India, Russia, Zimbabwe, Malawi and Cambodia

were also held to OGAC’s policies on the spending requirement.

This decision could especially challenge these country teams’ ability

to address local prevention needs.

Our report recommended that OGAC collect and report information on the effects of this spending requirement on its programs

and ask Congress to use this information to assess how well the

requirement supports the act’s key goals.

GAO also recommended that OGAC use this information to reassess its decision to apply the spending requirement to PEPFAR

funds in the nonfocus countries as previously mentioned.

In commenting on our report, OGAC acknowledged that countries face difficult tradeoffs with their prevention programs, and

Dr. Dybul reiterated that this afternoon. They agreed with our recommendation to collect and report information on the spending requirement; however, they did not agree that the requirement

should be applied only to the GHAI account.

Mr. Chairman, this concludes my statement. I am happy to answer any questions you or members of the subcommittee may have.

Mr. SHAYS. Thank you very much, Dr. Gootnick.

[NOTE.—The GAO report entitled, ‘‘Global Health, Spending Requirement Presents Challenges for Allocating Prevention Funding

Under the President’s Emergency Plan for AIDS Relief,’’ may be

found in subcommittee files.]

[The prepared statement of Dr. Gootnick follows:]

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Mr. SHAYS. Dr. Gayle.

STATEMENT OF HELENE GAYLE

Dr. GAYLE. Thank you, and thank you very much, Mr. Chairman,

Congresswoman Lee, and thank your subcommittee for the opportunity to join today to consider issues related to HIV prevention

programs funded by the President’s Emergency Plan for AIDS. We

clearly feel that ensuring PEPFAR achieve its success in reducing

HIV rates while we continue to focus on equitable treatment and

humane care for those already infected is a key critical challenge

for U.S. policymakers.

Organizations like CARE who implement programs at the country level share your commitment to make sure that we use these

resources in the most effective way as possible. We feel we owe

that to the people in those countries and clearly to the U.S. taxpayers who make these resources available.

We applaud the focus on prevention because clearly while treatment is critical, we can’t treat our way out of this epidemic, and

we really do need to think about how we are using the resources

to keep people from getting infected to begin with. And we know

that without effective prevention strategies, the numbers of infected individuals will continue to grow.

We are here because we feel strongly that PEPFAR and the U.S.

Government have shown real leadership and have contributed

major resources and critical momentum to prevention, treatment

and care, and we know that the program has already saved countless lives and provided much-needed support to communities, and

we strongly support the continuation of this vital initiative beyond

2008. And so we are here today because we believe in the program,

believe that it has a strong role, and want to provide instructive

feedback.

I would just say—and that feedback, that comes, from our experience, at the field level so that this program can be strengthened.

Just say from the outset there was a lot of discussion, the first

panel, about the ABC approach and whether this is the right approach. And I think we would go on record saying that we strongly

believe that a behavioral approach, approach that changes people’s

risk of acquiring this infection or avoids it altogether, is the right

approach. And so ours is not an argument about the merits of an

ABC approach, but rather a look at how the current legislation

may be construed in ways that don’t allow for a balanced approach

to the use of an ABC and behavioral change approach.

And I also say this as somebody who worked in the U.S. Government for 20 years and was responsible for developing program

guidance, and understand that what may be written at one level

has huge implications in how it actually gets translated at the

country level. So it is with that perspective that I want to talk

about some things that we think would really help and make more

effective the current program and make a bigger difference in lives.

So I want to talk about, first of all, the importance of being able

to more flexibly implement the current guidance to best respond to

the needs at the country level; that we feel that the issue of—as

a result of vulnerability of women and girls must be even more

strongly focused on; that it is important that a focus on engaging

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other highly vulnerable populations is incorporated; look at the better need to integrate efforts to address underlying determinants

that drive or compound vulnerability to HIV; and then finally to

look at a greater commitment to look at the impact and the evaluation and long-term sustainability of this program.

So I will try to be brief. I have a written statement that goes into

much more detail. But our first point, that in our experience on the

ground and resources for countries throughout the developing

world, the PEPFAR country teams responsible for interpreting program guidance have articulated prevention policies and programs

with a strong AB preference, leaving little room and funding for integrated local responses, HIV-AIDS prevention programs. And

again, we understand that this may not be the intent, but the experience on the ground suggests that this is a real issue.

Let me just give you one example from our many conversations

with CARE field staff in preparation for this hearing. In one of the

PEPFAR focus countries with a generalized epidemic, our country

office approached the PEPFAR country team with an innovative

proposal to work with sexually active youth who were exchanging

sex for money. Our proposal would have provided treatment for

sexually transmitted diseases, training for alternative livelihood so

that youth would not have to exchange sex for livelihood and for

money, and a variety of—a more comprehensive approach to address these issues.

This proposal was turned down for AB prevention funding because it was seen as not having a focus on those two elements, and

I think highlights the fact that there is a real difficulty and a bias

that works against having a comprehensive approach in the way

that programs are actually implemented in the field because the

funding categories of AB and other often end up being applied in

a very rigid fashion.

We have other examples of how this interpretation of the need

to partition funding works against a more comprehensive approach,

and as I stated in the beginning, our strong feeling is that all of

those components are important, and it is only through having a

comprehensive approach, a truly comprehensive approach, that the

prevention efforts can be most effective.

We believe that countries left to make the decisions, that have

the freedom to make their own decisions that meet the needs of

their country’s circumstances, will, in fact, apply the funds in a

way that provides for a balanced approach, and that countries don’t

need to be dictated to about the percentage of resources that are

used for any particular strategies. So we believe that countries left

to their own wisdom will, in fact, make good use and make—and

use a balanced approach in their effort.

Second, in sub-Saharan Africa, women represent 60 percent of

those infected with HIV and 75 percent of infections between the

ages of 15 and 24.

Women and girls in Africa are well served by the ABC model

only when they are free to make choices about abstaining from sex,

or choosing to remain in a relationship where faithfulness is meaningful, or to access condoms and negotiate their correct and consistent use.

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But wherever women cannot control the sexual encounters they

engage in, either for reasons of rape, abuse, gender

disempowerment, economic dependency and cultural practices,

ABC in its current formulation is significantly more problematic.

And we have a lot of examples from countries that have high rates

of rape and sexual exploitation where girls report that they feel

compelled to exchanges sex for food.

So clearly a message that focuses on abstinence and being faithful misses the point of the circumstances of these women and their

lives. And so having a focus that really addresses the needs of

women and the circumstances in which they find themselves is

critical.

I just give one quote, a predicament of one African woman interviewed by CARE which is all too widespread. She said, I am a

widow and have no family around me except my small children.

People in the community know I am poor and alone and thus more

vulnerable. As I have no one to protect me and no money, I am

often forced to provide sexual favors to officials, military and even

my brother-in-law.

We know that the OGAC has given more support to the issue of

including gender issues, but we feel that needs to be a much

stronger focus, recognizing that the ABC approach alone does not

take into consideration the entrenched cultural and social norms

that drive women’s vulnerability. But we know that a difference

can be made, and particularly when more focus is placed on changing male behavior.

Again, to illustrate, an African man recounted the following to

CARE field staff: My wife was raped, and I threw her out of out

of the house. A neighbor helped her and talked to me, but I refused

to listen to that woman. Later the men from the association came

to talk to me. They explained what had happened, and it wasn’t

my wife’s fault. They encouraged me to take her back into the

home, and I did.

So we know that, in fact, that by focusing on men’s behavior at

the same time, that we can have an impact on making a difference

in the circumstances that affect the lives of women.

Third point, the risk of HIV infection is significantly higher

among certain vulnerable populations, including sex workers, injection drug users, men who have sex with men, and prisoners and

sexually active adolescents. In many countries CARE HIV-AIDS

and reproductive health programs reach sex workers and those engaged in transactional sex through interventions designed to reduce the risk of infection or identify activities to expand livelihood

activities. PEPFAR’s funding is often supporting too little and too

little innovation in prevention programs among vulnerable populations.

And in view of the time, I won’t go into a lot of detail other than

to say that I think the focus on vulnerable populations has to be

included in that regard. And we think that the antiprostitution

pledge is particularly counterproductive in the fight against HIVAIDS.

Our fourth point is that as we look toward PEPFAR

reauthorization——

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Mr. SHAYS. Is this your final point? Because we need to conclude

here.

Dr. GAYLE. Yes.

It is important to learn from experience to date and begin to articulate components of a truly comprehensive HIV prevention policy that looks beyond the ABC formula and also addresses the

broader underlying issues linked to HIV vulnerability and related

issues.

In that regard we look at issues of poverty, gender inequality and

livelihood, understanding that all of that can’t be funded through

PEPFAR, but a better approach to integrating sources of U.S. funding, like food, nutrition, agriculture and economic growth resources

so that those components can be integrated with prevention will

clearly make a huge impact on the effectiveness of prevention programs.

And I won’t go into detail in the final one only to say that evaluation of this program and looking at the long-term impact of sustainability is also going to be critical.

So I will just close there and look forward to your questions.

Mr. SHAYS. You will have plenty of time to elaborate on any

point in your statement and questions.

[The prepared statement of Dr. Gayle follows:]

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Mr. SHAYS. Dr. Nkya, you are most welcome here. And the only

thing that concerns me is when I saw you in Africa, you had a

smile on your face. You look too serious to me. I need to see that

smile.

This is a wonderful opportunity for us to have you here, and I

just want to say before you speak, I don’t want to put pressure on

you, but our visit to Africa was made very special by getting to

meet you. You are a remarkable person, and you honor us with

your presence, and it is lovely to have you here.

STATEMENT OF LUCY SAWERE NKYA

Dr. NKYA. Mr. Chairman, Congresswoman Ms. Lee, members of

the subcommittee, I am honored to be here to speak on behalf of

the African continent, and more specifically for my people from

Tanzania.

Mr. Chairman, before I discuss or give the evidence of what is

happening with PEPFAR funding in Tanzania, I would like to give

a few statistics of information about the epidemic in Tanzania.

The AIDS Tanzania epidemic was first recognized in Tanzania in

1983 with three cases from the northwestern part of Tanzania

called Kagera region. Within 3 years, the epidemic had spread

throughout the whole country. That means it assumed a disaster

proportion, and that is why in the year 2000 our President, when

launching the AIDS policy, announced that AIDS was a national

disaster in Tanzania.

Mr. Chairman, I would like to bring to the attention that there

is only 1 case out of 14 of AIDS cases in Tanzania who are reported

to the nationalized control program, which is charged with the following of the money that are in the epidemic in Tanzania. That

means that the statistics which are released are really, you know—

and the reporting, and they are downplaying the epidemic and the

proportion of the epidemic in the country.

Out of all the cases reported, they referred that the peak of the

epidemic is between 20 and 49 years that contributes 73 percent

of all the AIDS cases in the country, which means that this age

group has been infected during adolescence or during their youthful

years; that is, between 15 and 20 years of age. Then 10 years later

that is when the epidemic starts showing up.

Another point to take, to note, is the, you know, preponderance

of——

Mr. SHAYS. Let me ask you to put the mic a little closer to you.

Just a little.

Dr. NKYA. Is the early age of infection in women. The peak is between 20 and 29 years. That means women are infected at a very

young ages compared to male counterparts, and that married people contribute 56 percent of all the cases of AIDS which are reported in the country as compared to the 32 percent of the singles.

And the currently AIDS infection in Tanzania now is 7.7 percent.

This does not mean that the prevalence rate has gone down, but

it is because it is based on blood donor, surveillance reports, which

have proved that people now who are going go to donate blood have

known about HIV-AIDS, so a person who suspects himself as being

infected will not go. So this has brought down the infection rate.

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Let me tell you that we aimed at treating only 1,200 people out

of 2,000 who are infected, but this is only in urban areas, and the

legality is if your city or county is less than 200 percent—200, that

means a lot of people infected who could be healthy and lead a

meaningful life—are denied opportunity for treatment. I don’t know

who brought in this cut point, but it is there.

Let me say that the initial response is good, and I do have a very

good HIV prevention strategy which includes ABC, plus other contributing factors like using the same instruments, ear-piercing and

injections, and more on cultural behaviors and beliefs which contribute to the, you know, spread of the HIV-AIDS.

Now, what about my experience now with PEPFAR fund. And I

am going to talk in relation to for trust fund.

Mr. SHAYS. Your experience with what?

Dr. NKYA. With PEPFAR funding program, the AB program.

I am going to talk about my experience with FARAJA Trust

Fund, which is an agency which I am directing. Before I started

working with Deloitte through a program called ISHI—ISHI means

live. It was a campaign which was targeting young people in

Morogoro municipality with one message, that you should wait

until marriage, and if you cannot, you can use a condom and engage in dialog.

Dr. NKYA. Yes. The message is this: It means wait, don’t be

afraid. You know, engage him in a dialog or her in a dialog, or abstain. If you cannot, use a condom.

That was the message. And you know, we produced a lot of

teachers with the message. And it was all over the radio program,

television programs, even the national television. Unfortunately

during the last session of the Parliament, this message was banned

from being transmitted through our television programs in Tanzania.

Dr. NKYA. It was a successful program, it was a 1-year program.

We had more than 7 million shillings from Deloitte. And it give the

youth an opportunity to discuss openly about HIV/AIDS, to get access to condoms, the few condoms which I had because we could

not access new condoms through the ministry because they were

not available, there were no funds.

And then the second message came in 2005, 2006 through Family Health International. Now the message changed, it was now

AB, that was abstain or change your behavior. That was the message that was being given to the young people. Now what was the

reaction? The reaction was very confusing. The young people would

come to us and ask us, are you going mad? It was a bit embarrassing. You have been advocating condom use, behavioral change and

abstinence where it is applicable, but now you change and say OK

guys, it is time to be more realistic, abstain from sex until you get

married—as if everybody’s going to get married—or change your

behavior, be faithful in marriage.

So several questions came up. The first question was, what will

happen to the sexually active young people who are HIV positive?

What will happen to the couples who are HIV positive if free

condoms—because many people in Tanzania are poor—if no free

condoms are available? They’re asking me, you know, have you

changed the behavior and the culture of the people whereby, you

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know, rich men, especially affluent men, in the community that

they are rich and influential, the number of concubines or sexual

partners they’re going to have, they came to ask me, you know,

don’t you know, mom, that the problem here is poverty, not even,

you know, we being promiscuous.

And this brought me back to the project which we started in the

brothels. It is one of the biggest brothels where a lot of young

women were in the 1990’s, and I talked with one and asked her

what is your problem, why do you have to leave your home and

come to this place, which is filthy and they’re being abused by men.

She said, look here—they used to call me mother-in-law—motherin-law, look here, it is better to die slowly than to die of starvation

to death, and better off dying 10, 20 years to come if the message

is this, rather than dying today because the 10 years will give me

time, first of all, to work and build a house for my children, and

give enough time for my children to grow up and to become selfreliant, and also be able to purchase a farm. And then very slowly

given enough time to repent of my sins, that’s what they told me.

Then probably, if I would give another example, another example

is about a young girl who is 15 years old and she has a child. This

woman, this girl asked how come she have a child. She told me

that she was forced into marriage by her father, and that is, you

know, perfectly in order, depending on the culture of our people in

Tanzania, to marry a man as his official wife, and when this man

died, she was forced to be inherited by the older brother of the dead

man that she managed to run away and escape.

Now what was her refugee? How could she leave with two children? So she had to engage in commercial sex work in order to live.

And now I’m talking to her, telling her now, you see, if we check

you—you come for physical, and we refer to you as either negative

or positive, you should be abstaining from sex. Then she asked me,

what am I going to do? How am I going to feed my children? My

mother also expects me to support her from where I am now.

That’s the issue, Mr. Chairman. Let me say that the approach

and the policy of AB does not take into consideration the culture

of the people in the developing countries. It does not take into consideration the socioeconomic situations, things like poverty.

Let me tell you that even empowering women or gender empowerment will never succeed if we don’t address the issue of poverty, especially among women. This is evidenced by a program I

conducted in a brothel whereby I was able to empower those

woman economically, and we managed to remove more than 67 percent of those women from prostitution, they are living, and their

children are now going to school.

Mr. Chairman, I have a lot of testimony, but——

Mr. SHAYS. Well, maybe we’ll get some of your testimony from

the questions, but I remember your conversation with us, and as

you—this brothel, as I remember, had literally hundreds of women,

didn’t it?

Dr. NKYA. There were about 450 women, and we managed to rescue 270 women who were HIV negative to stop prostitution, and

they moved back into their homes. The remaining, we were able to

give them some money so that they could take care of themselves.

Although they were positive, they could do some work, ideas to get

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food, to meet their present medical requirements and to feed their

children. And eventually, as I’m talking today, Mr. Chairman, the

brothel has been demolished, and these women now are living, they

are respected and they’re living.

So that is a living example which has been by many people and

organizations in Tanzania and some organizations from the countries that empowering women should complement economic empowerment because poverty is the basis of HIV. HIV is epidemic in

our countries. Whether you are infected or not infected, you are in

the rural area or in the urban area, if you are poor, you are going

to engage into behavior which is going to put you into risk of getting infected. I’m not forgetting that.

44 percent of our population is young people. That means these

young people, as we have seen in the statistics here, they are more

vulnerable than the others. So let’s say that they’re all vulnerable

to getting HIV infection. So telling them to abstain, that is not

really going to hold water, and backed by the fact that we did the

survey in Morogoro in year 2000 and year 2003, whereby we found

that the minimum age of sexual activity started from 10 years, and

for some were 9 years of age.

So given that basic fact, and I think, you know, it would be better off if HIV prevention strategies, that means including AB plus

the other cultural factors, and economic factors which are contributing to this plague of HIV/AIDS.

Mr. SHAYS. Well, we will get into some of this in the questions

that Ms. Lee and I will be asking. So thank you for your testimony.

I’m struck by the memory that as you went to this brothel to deal

with these women, as I recall, your husband, who traveled, got a

note from one of his friends saying your wife has become a prostitute. He didn’t quite understand the role you were playing. You

are obviously a magnificent lady.

[The prepared statement of Ms. Nkya follows:]

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Mr. SHAYS. Dr. Green.

STATEMENT OF EDWARD GREEN

Dr. GREEN. Thank you. Mr. Chairman, members of the Government Reform Committee, thank you for inviting me to participate

in this important hearing on AIDS prevention and PEPFAR. I’m a

senior research scientist at the Harvard Center for Population and

Development Studies.

For most of my career I have not been an academic. I’ve worked

in less developed countries as an applied behavioral science researcher and as designer and evaluator of public health programs,

mostly under funding of USAID. I’ve worked extensively in Africa

and other resource-poor parts of the world. I’ve worked in AIDS

prevention since the mid 1980’s, at which time I was working in

the field of family planning and contraceptive social marketing in

Africa and the Caribbean, and I’ve served on the Presidential Advisory Council for HIV/AIDS since 2003.

I might add that I worked with Dr. Nkya in 1984 in Morogoro

in that very project for sex workers. We were helping them not get

infected or pass on infections, treat their STDs, and provide income

generating skills if they wanted to get out of sex work, which the

great majority did.

I would say that obviously abstinence is not the very relevant

message if you’re an active sex worker, but then neither are

condoms and clean syringes, the primary message that you would

bring to primary schools.

Since my time too is very short, let me just cut to the chase. And

I feel that amending the 2003 act that requires that 33 percent of

PEPFAR prevention funds be spent on abstinence and fidelity programs, moving this would be a bad move, removing this earmark

would remove the essential primary prevention foundation from

the U.S. Government response to the AIDS pandemic. It would

leave only risk reduction, which is different in intent and effectiveness from true prevention.

A risk reduction approach assumes that behavior contributing to

morbidity and mortality cannot be changed; therefore, the best we

can do is to reduce risk. And this was our strategy with those sex

workers in Morogoro. Risk reduction alone has never brought down

HIV infection rates in Africa. This conclusion was reached by three

separate studies under the rubric of the USAID funded ABC study

in 2003, and later. It was also reached by a U.N. AIDS study of

a 2003 study condom effectiveness review by Herston Chen, and it

was the conclusion implicit in the UN/AIDS multi-site African

study published in 2003.

Prevention based on risk reduction had some early success in

Thailand, and later in Cambodia, but never in Africa, or at least

outside of the few high risk groups. Now PEPFAR and USAID lead

the world in AIDS prevention, promoting a balanced and targeted

set of interventions that include Abstinence, Being Faithful and

Condoms for those who cannot or will not follow A or B behaviors.

And I’m the person who said this is in spite of formidable and continuing institutional resistance to change, and maybe we can talk

more about that.

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Removing primary prevention from this mix by removing the

present earmark would almost certainly return AIDS prevention to

the era when HIV prevalence continued to rise in every country in

Africa, with the exception of Uganda and Senegal, the first two

countries in Africa to implement ABC programs. Since then, ABC

programs and changes specifically in A and B behaviors, especially

in B behaviors, as has been said earlier, which is measured in the

decline in the proportion of men and women reporting two or more

partners in the last year, are credited with reducing HIV prevalence not only in Uganda, but in Kenya, Zimbabwe and Haiti, and

possibly in Rwanda. These last three countries’ successes were all

the more remarkable considering the political and economic devastation they’ve suffered.

As was mentioned, a consensus statement published for the 2004

World Aids Day special issue of the Lancet proposed that mutual

faithfulness with an unaffected partner should be the primary behavioral approach promoted for sexually active adults in generalized epidemics. Abstinence or the delay of age of sexual debut

should be the primary behavior approach promoted for youth. This

represents a fairly marked departure from many previous prevention approaches which emphasized condom use almost exclusively

as the first line of defense for sexually active adults for all types,

in other words, regardless of the country, the culture or the type

of epidemic. This statement was endorsed by over 150 global AIDS

experts, including representatives of five U.N. agencies, the WHO,

the World Bank, as well as President Museveni, and two of the authors were myself and Dr. Gayle.

A growing number of public and international health professionals recognized the previously missing AB component of ABC as

logical, sensible, cost effective, sustainable, culturally appropriate

interventions for general as distinct from high risk populations.

Moreover, the evidence is clear that these components work, and

that risk reduction alone has not lead to a simple success in generalized epidemics.

I wish I had more time to present more evidence, I thought we

were going to be kept on our 5 minutes.

For example, DHS, Demographic and Health Survey data showed

that higher levels of AB behaviors—and it’s assumed by many that

we already see that, including people who work in the AIDS field

ought to be familiar with the data. For example, only 23 percent

of African men and 3 percent of African women reported multiple

sex partners in the last year, according to the most recent DHS

surveys. Among unmarried youth 15 to 24, only 41 percent of

young men and 32 percent of young women in Africa reported premarital sex in the last year. This means that most African men

and women practice B behaviors, or do not have outside sexual

partners, and most unmarried African youth do not report sexual

intercourse in the past year.

I hate to use the controversial A word, abstinence, but that’s

what surveys show. And I wish we could take away the word only

after abstinence.

Moreover, the trend in Africa is toward higher levels of A and B

behavior, it is toward incrementally lower HIV prevalence. HIV

prevalence is an average of 7.2 percent for Sub-Saharan Africa in

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2005, compared to 7.5 percent in 2003. I mention this because critics of the African ABC model often depict African men in particular

as incapable of monogamy or fidelity, which is simply not true.

When critics of fidelity and abstinence programs argue that these

behaviors sound nice but don’t get the reality of Africa, one only

needs to look at the available behavioral and epidemiologal evidence—this is from DHS, studies by Population and Services International of Family Health International, a number of USAID recipients of funds.

In conclusion, I hope Congress will take no actions that would seriously undercut the one major donor agency in the world that is

conducting effective AIDS prevention, the generalized epidemics by

in effect removing the very interventions that have been proven to

have the most impact. I believe that the simple effect of the African

model of AIDS prevention is still so new and different from the old

way of doing things that without some direction from Congress, the

bureaucracies involved in guiding implementation would probably

fall back into old habits and once again limit AIDS prevention to

its reduction to condoms, drugs and testing. These three are all

necessary, but A and B is the missing part.

If I could just take a moment to answer the question that you

were asking the government panel, why not simply leave allocations to the countries themselves. We had an example of that happening in 1998, the Ministry of Health in Jamaica convinced

USAID, they said basically we feel we have the expertise in our

government and our NGO’s, give us the money and we’ll give you

the results. After 5 years, we’ll account for every dollar to see how

we do results-wise. And what they did, what Jamaica did is they

developed a program very much like that of Uganda or Senegal, it

was a balanced ABC program, and I was one of the three American

evaluators, and STD rates were coming down, and it seemed like

HIV rates were coming down, and it was one of the better programs I’ve seen in developing countries.

I think where the problem is, Mr. Chairman, is with us, is we

technocrats from the United States and Europe, we’re used to the

American model of AIDS prevention which is focused on MSM and

IDU, focused on high risk groups. And so if you come from a family

planning background the way I do and you’re used to preventing

contraception, which I am and USAID is institutionally, and all of

a sudden, you find out that Uganda and some other countries are

quietly doing something a little bit differently and having results,

it takes a while to change your thinking and to change what the

bureaucracy does. And when you think of all the grantees, the contractors and what they do, what they do best, it takes some change.

So I really think that if the earmark were removed right now, we

would go back to the AIDS prevention before 2002, and we

wouldn’t be having as many successes as we now have. Thank you.

Mr. SHAYS. Thank you, Dr. Green.

[The prepared statement of Dr. Green follows:]

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Mr. SHAYS. We’re going to start with Ms. Lee.

Ms. LEE. Thank you very much, Mr. Chairman.

Let me first say once again, thank you for this hearing. It’s very

important. And as I listen to the testimony, the only thing I can

think of is we’re talking about saving lives right now, and finding

the best way to do that and to help people live longer lives until

we do find a vaccine or a cure. And I need to say up front that I

think we need to repeal this earmark. I intend to do everything I

can do to try to get that repealed.

Dr. Green, now you’re at Harvard University, and I appreciate

Harvard and know of your good work and Harvard’s good work

throughout the world. And I have to ask you, though, in one who

believes that ABC makes sense, abstinence, be faithful, use

condoms, why in the world would you believe that ABC is not what

we’re talking about when we talk about abstinence, be faithful, use

condoms, I mean, we’re talking about a balanced comprehensive

approach. And with this earmark being what it is, we have seen

in and GAO has indicated that this is probably hindering our efforts in the prevention arena. And let me just say, I was at the last

AIDS conference in Toronto, the rest of the world, quite frankly,

disagrees with what you’re saying, Dr. Green, the rest of the world

understands and gets it. The rest of the world believes that they

know how to develop country-specific plans that come up with their

specific ways of addressing prevention, care, treatment. And so why

would we not listen to what works in countries and not be as heavy

handed in our approach?

Dr. GREEN. With all due respect, that’s exactly what I’m doing,

my rethinking AIDS prevention in 2003 was looking specifically at

the first five or six countries to experience prevalence decline. I

also have to say, with all due respect, that the people who attend

the global AIDS conference are not a cross-section of Africa, Asia,

Latin America—this is not the best of the world.

Ms. LEE. Well, Dr. Green, what countries do you think would not

want to see the earmark repealed?

Dr. GREEN. What countries would not want to see it repealed?

Who would you ask in those countries? If you put it to a vote of

the people, the majority of the population, I’m certain that all of

the countries would want to keep the earmark there if they understood that——

Ms. LEE. They knew they could get some money.

Dr. GREEN. No, if they understood that AIDS prevention would

go back to risk reduction only.

The head of the National Aids Committee for Kenya 2 or 3 years

ago posted a complaint on an AIDS discussion group on line that

the ministry—that the government of Kenya had received an additional $10 or $15 million for AIDS prevention. And part of what the

government wanted to do was have a program to reach kids before

they become sexually active, to promote abstinence or delay of sexual debut, not abstinence only, but to include. And they were told

no, this is money from the U.S. Government, it has to be spent on

condoms. And he wrote a letter to complain, and I asked if I could

put his letter in my book, which I did. I, again, say I think the

problem is with we technocrats—and I mean European and American experts who work in AIDS, we’re used to thinking in terms of

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the American epidemic, the European epidemic, high risk groups—

which are some of the first groups we went after in Africa and the

Caribbean, I was working in the Dominican Republic in the mid

‘80’s. We went after—we tried to reach sex workers and their clients. But again, if you look at the data, most Africans, most people

everywhere are already engaged in primarily B behaviors, and

young people are primarily engaged in A behaviors. I don’t even

like the word ‘‘behavior change.’’

Ms. LEE. Dr. Green, all I’m saying is that the conditionality aspect of this, even telling a country that they must have a strategy

that only uses condom as part of their strategy——

Dr. GREEN. I’m glad you agree that’s wrong.

Ms. LEE. I’m talking about ABC; I’m talking about allowing

countries to come up with their culturally specific, their scientifically specific, their gender specific, their overall approach to how

they want to deal with this pandemic. So no, we shouldn’t say——

Dr. GREEN. I think we should do that, I think we should find

out——

Ms. LEE. I think we shouldn’t say if we don’t like the way you

approach it. What I’ve heard—and again, I think that we, at the

international AIDS conferences and throughout the year we hear

from many, many people around the world who want to get rid of

this earmark because of one point, they want to be able to be

unencumbered by their approach to addressing this pandemic because it’s so serious.

And with regard to women, what happens to women? We all

know what happens to women. We heard earlier, the empowerment

of women, women’s equity, gender equity, female condoms, all of

these strategies.

Dr. GREEN. That’s part of the B strategy. If faithless men are infecting their wives, then it’s the men’s behavior that needs to

change, and that’s B.

Ms. LEE. But what about women and the access to condoms? If

a country or the United States has precluded the funding for that,

what if women——

Dr. GREEN. Well, they shouldn’t.

Ms. LEE. Well, the earmark, in many ways, precludes a comprehensive balanced approach.

Dr. GREEN. I don’t see it that way. There is a larger pie now to

divide up than there was a year ago, 2 years ago, 3 years ago. As

I’ve been saying for some years now, as we have gained more to

work with in AIDS prevention, let’s not put all of our money into

programs that have not worked in Africa and the Caribbean.

Ms. LEE. I’m not talking about putting all of our money into programs that don’t work. All I’m saying is why can’t we just repeal

the earmark and say to countries, develop whatever plan makes

sense to address this terrible deadly disease. That’s all I’m saying,

period, dot dot.

Dr. GREEN. I agree with the intent of what you’re saying, but I

think in practice what happens is poor countries ask for the program that they know that there is money for.

Ms. LEE. Oh, Dr. Green, come on. You know how you’re sounding, very patronizing. Countries have the ability—and I’ve spent

quite a bit of Africa——

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Dr. GREEN. I lived there.

Ms. LEE. Countries around the world have many unbelievable

people who know how to address epidemics, pandemics, disease if

only provided the resources and the support and the technical assistance. I can’t believe that in any country at this point, if we

didn’t help develop and go in and do the things we need to do to

support their efforts, that they couldn’t be successful. So I can’t buy

the poor country notion.

Dr. GREEN. Again, I agree with your intent. I wish there was

some way to let these countries choose for themselves without imposing our priorities on them.

Ms. LEE. Well, I think we can.

Let me just say to Dr. Gayle, I want to congratulate you on the

successful conference in Toronto, it was really quite successful,

quite powerful. I’ve been to four, and intend to go to the next one

in Mexico City. And as I was thinking about Toronto today, I said

when in the world are we going to have an international AIDS conference in America? And then it dawned on me that we have certain travel restrictions for people living with HIV and AIDS that

precludes us from having such an important conference in our own

country.

So I’m going to work with others to try to—again, I hate to keep

trying to repeal stuff, but we want to get rid of that, too.

You know, I mean, I think that the world is a small place now,

and we need to figure out ways to work together. And for us not

to be part of this conference and not to be able to have it on our

own soil to me is just downright wrong and, quite frankly, it’s immoral. I was proud to carry the American flag in a rally in Toronto.

I knew I couldn’t carry the American flag in a rally here in America at an international AIDS conference. Mr. Chairman, I think

that’s pretty bad and it doesn’t bode well for our standing in the

world.

And so I just to want congratulate you and also just to ask you

your take on—you heard what Dr. Green said about the conference

in terms of who goes and who doesn’t go. What is your take on the

abstinence only policy, and by the rest of the world, the rest of the

world that didn’t come to the international AIDS conference.

Dr. GAYLE. Yes, thank you. And we appreciate you and the

Chair’s leadership in this issue. And I also appreciate your comment about repealing the travel restrictions. We really would love

to see an international conference on U.S. soil again and feel that

there’s a real value to it because I think it goes along with the

leadership role that the United States is playing. And that’s why

we feel so strongly about getting it right because we feel that not

only are the resources that the U.S. Government contributes critically important, but the leadership role that the U.S. Government

can play and does play is critically important. And so the consistency in that leadership role we feel is extremely important on all

these issues.

I would disagree, I think the International Aids Conference, I

disagree with Dr. Green that the International Aids Conference is

a wide cross section of people working on HIV at a grassroots level

as well as the international arena. So while perhaps it isn’t perhaps totally inclusive, 24,000 people working on HIV from all difVerDate 11-MAY-2000 10:03 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00132 Fmt 6633 Sfmt 6633 C:\DOCS\35621.TXT HGOVREF1 PsN: HGOVREF1
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ferent continents I think does speak to a pretty inclusive gathering.

And we didn’t take a poll on what people thought about the restrictions, but I think it’s fair to say that there are concerns because

not only does what the U.S. Government do impact U.S. Government funding, but again, the United States plays a strong leadership role. And so I think it does also influence other people’s thinking about what is the right way to do things. And so what we do

with our funding does influence the world, and I think sending a

message to the world that we don’t see this in a comprehensive

way, that we do have biases, has an impact. And I think all efforts

to really allow for countries to make decisions to have an integrated program, just like we talk about combination treatment, we

also have to talk about combination prevention. There is no onesize-fits-all, it is by the ability to make programs that fit the country needs and country circumstances that we can have the most effect prevention response.

And I would argue that as somebody who’s been doing HIV prevention programs for over 20 years, I don’t remember a time when

we as public health professionals said that condoms were the only

answers. So this idea of going back to that day, I’m not sure where

that perception comes from. I think that the understanding and the

evidence around what works for HIV prevention has evolved. And

so I think it is not legislation that leads to the understanding that

a comprehensive approach is right, it is evidence, it’s the fact that

we have growing evidence that this is the right approach.

So I don’t think the clock will be turned back, whether you think

that it was there or not. I don’t think that it is legislation that

keeps people looking at a comprehensive approach, it’s the evidence, it’s the evidence that says this. And I think whether it’s

technocrats or whether it’s the country level, it is a comprehensive

approach that must move forward. And I don’t think that it is a

need for a proscriptive approach what is what will keep a comprehensive approach on the books and in our policies and in our

program, it’s the fact that we all know that is the best way to have

an impact on prevention by doing it in an integrated fashion, doing

it in a comprehensive way. The evidence is there, and I think that

stands for itself.

And I would just add that I do think that the issues that were

raised around making sure that we address the other issues, the

issues of poverty, the issues of gender and equity, we must do that

in order to support a behavioral prevention strategy because people’s behavior, individual behaviors occur in the context of social realities.

Mr. SHAYS. Let me jump in here, I’d like to take some time.

Dr. Green, first let me say you bring tremendous credibility to

whatever position you take based on the work you’ve done for so

many years. So even if Ms. Lee does not agree with you, it’s important that we hear exactly what you think, and then kind of wrestle

those out.

I would like to know, coming all the way from Africa, what would

be the most important thing that you would want us to know about

the continent as it wrestles with this disease? And what is the biggest area that you would want, Dr. Nkya, to impress upon us so

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that I’m very clear as to the most important thing that you want

us to know.

Dr. NKYA. Thank you, Mr. Chairman.

Coming all the way from Africa, I’d like to insist that AIDS is

a disease of poverty. And it is compounding on the threat of disease, poverty, it is also compounding on the socioeconomic impact

and even the physical well-being of the people, which also in turn

compounds the vicious cycle of compounding poverty itself.That is

one.

Two; it is unfortunate that we in Africa, especially in Sub-Saharan Africa, we are always the recipients; we totally depend on external support on most of our intervention packages. So whoever

comes with assistance in HIV intervention, they come with their

own prescription for intervention package. Whether we agree to it

or not, we have to adhere because we need the money. And it’s unfortunate that we cannot even become a bit flexible to fit into our

own, you know, what is really workable in our own environment.

So what I would like to, you know, ask you or request from this

package or from the funding is like what Congresswoman Lee was

saying, that if countries were given the opportunity to choose and

to plan for themselves, could it really have an impact on the spread

of the disease? I’m saying yes. Yes, because, for example, in Tanzania, we recognize that women are very vulnerable. We know that

when we are addressing ABC, and there are free condoms for those

who want to use condoms and have the information, the impact is

really good, but now we cannot produce condoms because most of

the money for condoms came from the United States of America.

So now we do not have access to free condoms.

Money comes for treatment and for prevention for mother to

child. It’s unfair to just giving the women some medicine to prevent

the child from getting infection at birth and while the child is newborn, but after that there is no form of support of counseling. So

I would like to see more money being allocated to provide holistic

HIV—I would like to see some money being allocated to provide holistic HIV/AIDS prevention package, like for primary schools, very

young children we can talk about abstinence and behavioral

change. For the grown up children, because we know, whether we

want to talk about it or not, they are practicing sex.

We should be able to give them more information about, you

know, productive health, more information about behavior changes

through life skills training, which is not really widespread in Tanzania and that’s why we have so much AIDS.

Mr. SHAYS. What I find myself wrestling with, and I’d like all of

you to respond to it, and I’ll start with you, Dr. Green, when I

heard the first panel talk about basically a holistic approach, looking at all abstinence as well as condoms as well as be faithful and

so on, what I’m realizing though is, from the testimony that we’ve

heard from this panel, that we really separate them. And so I’m

thinking, is it a crapshoot in a way? Do some students only get abstinence and some students only get condoms, and is it really an

integrated program because of that? And you know, you, Doctor,

are getting me to think that way, that if that’s where the money

is—first off, I believe that folks will go wherever the money is, I

mean, they’re going to design a program, we give them money

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they’re going to design a program to be able to attract that money.

Do you get the gist of my question, Dr. Green?

Dr. GREEN. Did I get the question?

Mr. SHAYS. Do you understand what I’m asking?

Dr. GREEN. Not quite.

Mr. SHAYS. OK, let me ask it this way. If we are mandating that

a certain amount be for abstinence—there’s going to an abstinence

program that’s provided, correct?

Dr. GREEN. Yes.

Mr. SHAYS. But I suspect in most instances, the abstinence program is not going to also tell you you can use a condom, and that

you’re going to see a program in abstinence. And that you might

see a program that, you know, is providing condoms, but you don’t

integrate it. So it’s not like what people are suggesting. You know,

trying to persuade a young person about abstinence is the best

way, but here is a condom if you’re not going to go that route, it

almost seems like a contradiction.

Dr. GREEN. Well, I agree with your implicit criticism of compartmentalizing, you know, this program is for this and only this, and

the B and the C are only for the—and that’s not integration and

that’s not real life and that’s not responding to people’s actual

needs. So I think we’re in agreement there.

I think the government panel testified that after the age of 14,

that the B and C message are brought in. You know, if there is evidence that children are sexually active at age 10 or 11 and that’s

their situation, you can’t change it—I would try to change it—then

you need to bring in condoms earlier. So I’m not in favor of abstinence only.

You know, if we just look at the Uganda model, and we can look

at the other models, Senegal and more recently Kenya and so forth,

I didn’t see much evidence of condoms only. I have pages of teachers books and student books from primary schools in Uganda, and

condoms are part of the education. So there should be integration.

I don’t know that much about how PEPFAR is integrating, but

that’s the way it should be.

Mr. SHAYS. Dr. Gootnick.

Dr. GOOTNICK. Thank you. I think the particular lens that GAO

can bring to this discussion is really two-fold. One, if you offer the

U.S. Government implementers in the field, the USAID and CDC

staff in the field some degree of candor and ask them how this

spending requirement affects their programming, you’ll get some

interesting information. That’s the first thing. And second——

Mr. SHAYS. And the interesting information is?

Dr. GOOTNICK. Well, the interesting information is that more

than half of the respondents will tell you that while Office of Global AIDS coordinator will certainly allow an integrated program, an

ABC program—and if Ambassador Dybul was here, I think he

would tell you that these programs, the vast majority of them are

integrated. But if you speak to the implementers in the field, they

will tell you that program dollars in these different buckets has

consequences, and that there are programs that could be much better integrated but for the spending requirement that the program

works with.

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The second point is if you look at where the dollars have had to

move, and the difference between 2005 and 2006 really is enlightening. And there will never be another set of data like the transition between 2005 and 2006 and that’s because 2006 was the first

year that the one third abstinence requirement became law.

So looking at what happened in the shift between 2005 and 2006,

it is informative that no other data set will be. And as I mentioned

in my prepared remarks, if you look at in the aggregate, AB programs went up very significantly whereas prevention mother-tochild transition and condoms and related program activities remain

level. If you look at a country level, you see some real tradeoffs

that have been made there. If you look at a country like Zambia,

you see that there has been nearly a 40 percent cut in condoms and

related program activities at the same time that abstinence programs have risen. You see in that country also as you well know

that sex workers, migrant populations, and other vulnerable populations are perhaps key to the epidemic there. You see that sexual

transmission in discordant couples, in a couple where one individual is positive, the other is negative and may not know it, the rates

of transmission in discordant couples are very similar to the rates

of transmission in the general population, so——

Mr. SHAYS. I’m not getting the point as to how that relates to my

question.

Dr. GOOTNICK. Well, the point is that an integrated program—

the U.S. Government implementers will tell you that the counting

of the money in the buckets of abstinence, faithfulness and

condoms related programs does hamper their integration. And you

will see, if you look at the dollars, considerable shifts in program

dollars in order to meet the spending requirement.

Mr. SHAYS. OK, thank you. Doctor.

Dr. GAYLE. Yes, briefly to add to that, I would agree our experience at the field level is that while the guidance, strictly speaking,

does allow for an integrated approach, the way it’s practiced inconsistently and the guidance that is used does bias programs often

in an AB category where the preferred program would be to implement an integrated approach so that we do have in the field programs that end up being not integrated, only having one element

or the AB approach not being able to integrate condom funding,

and again, not because that is necessarily explicit, but the guidance

is confusing, and it ends up being interpreted in the field in a very

compartmentalized way.

Mr. SHAYS. Does your organization provide all three, ABC, all

three?

Dr. GAYLE. Right. But we’re in 70 different countries. So at a

country level, the guidance is applied differently. As an organization overall, yes, we definitely focus on a comprehensive integrated

approach. But by country by country, the way the guidance is interpreted pushes people in one direction or the other, and compartmentalizes programs much more than the original intent would

have been.

Mr. SHAYS. OK, thank you.

Dr. NKYA. But Mr. Chairman, my concern is this; whether we

talk about ABC, but for poorer countries like Tanzania, you can,

you know, violate the rule and talk about ABC. But there are many

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people who would like to use the condom, and young people cannot

access condoms because they’re not there. I go and ask the minister

of health what is happening, we don’t have condoms, we says we

are not getting money from the United States of America to buy

condoms——

Mr. SHAYS. Let me ask you this; OK. You’re not getting it from

the United States, but you’re not getting it from anyone either?

Dr. NKYA. We’re not getting it from anybody else because the

others who are funding something like integration impact, and others have some other interests like working with other organizations, but initially, all the condoms in that country were being

funded by the USAID from America. So now we don’t access—for

the past 5 years—4 years we don’t access free condoms for anybody

in that country.

Mr. SHAYS. So I make an assumption that if condoms aren’t

available, we’re basically transmitting AIDS. If condoms aren’t

available, sex—I mean, I have not yet known a society that’s decided to give up sex. So what I make an assumption is, from your

testimony—and it’s pretty powerful because, unlike the others,

you’re there, you’re working with young people all the time, and

you’re saying and testifying before this committee that condoms are

not available. That is a powerful message because we know that is

one way to prevent the transmission of AIDS. We could talk long

and hard about whatever we want to talk about, the value of abstinence, but if in the end condoms aren’t available and young people

and older people are having sex, they are at huge risk. And what

I’m trying to understand is why would it have to be, Dr. Green and

Dr. Gootnick and Dr. Gayle, if we are saying it’s an integrated approach, why can’t it include all of the above? And why, in the end,

are condoms not available? Are they that expensive that—so someone help me out here.

Dr. GAYLE. Well, I guess I would agree with the earlier statements, that in order to have the best chance at having a balanced

approach is to let countries develop programs that meet their needs

at the country level, and that countries make those decisions about

what proportion gets spent on what part of the ABC approach

based on what their greatest needs are. So that if condoms and

condom shortage was the greatest need for a given country, that

they have the ability to use resources for condoms. If, on the other

hand, they had other funders that allowed them to use those resources for purchasing condoms, that more focus be put on the

other parts of the approach, so that countries have the ability to

make those decisions without having arbitrary proportions that

need to be spent, and can develop a truly integrated approach.

So I think the lack of funding for condoms is reflected by the inability too use resources to spend it on what countries need it for

the most.

Mr. SHAYS. I’m going to react to something—thank you. Dr.

Green, I’d like you to react to—I’m going to tell you what I’m hearing and I’d like you to react to it.

What I’m hearing is a better and more powerful message than

I thought in support of abstinence programs. I thought that the

first panel did a better job than I anticipated. You believe in this

program and you carry a lot of weight; you’ve had tremendous exVerDate 11-MAY-2000 10:03 Jul 16, 2007 Jkt 000000 PO 00000 Frm 00137 Fmt 6633 Sfmt 6633 C:\DOCS\35621.TXT HGOVREF1 PsN: HGOVREF1
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perience and you do research and so on, so that carries weight with

me. But I’m left with the fact that if it’s a mutually exclusive

issue—in other words, if you go the route of abstinence, you are not

providing enough condoms, for instance, as one preventative way,

then one, it isn’t know an integrated approach. But No. 2, if I had

my child—let’s not use my child, let’s just use any child, if they

only had one choice, they were going to have an abstinence program but still have sex, I’d prefer they had a condom instead of an

abstinence program and still have sex. I mean, so react to what I’m

saying.

Dr. GREEN. It seems like we always fall back into talking about

abstinence versus everything else. Keeping in mind that both government panelists and I have reported, which is that it’s part of reduction, it’s not having—what drives epidemics, sexually transmitted epidemics whether heterosexual or homosexual, what drives

these epidemics is having multiple concurrent partners. And what

brings prevalence down at the population level is not having multiple concurrent partners.

So I wish I didn’t always have to be put in the position of defending abstinence—and we’re leaving out the thing that works best. So

having said that, how often have I heard African health educators

and others say if it was—you know, it’s not if it was only one program, they would say if it was only one behavior, I would want my

child to abstain and not have sex using a technology that, if used

consistently is 80 to 85 percent effective in reducing HIV infection.

The problem is that rarely are condoms used consistently in Africa, in the United States, anywhere in the world. I didn’t want to

bring this up because it just makes me even more unpopular than

I probably already am to talk about uncomfortable data, but there

is an unwanted and unfortunate correlation between populations

where you find more condoms available and people use them more,

and higher infection rates.

The demographic and health surveys, we now have serologic data

to go with behavior data, so we can easily cross tabulate those who

are—we can look at the sero status of those who are practicing A,

B and C behaviors. And the first countries we have evidence from

from the demographic and health surveys—and I don’t think these

have been published yet because there are uncomfortable data—

from Tanzania, from Ghana, from Uganda—I think there may be

one other country—we see that condom users are more likely to be

HIV infected than non-users. This is counterintuitive, it’s not what

we want, it’s not where we put billions of dollars, but it may be

because—it’s probably because condoms are not used consistently

usually, and second, there’s a disinhibiting effect. If the message is

you can do what you want, be sure to use American brand

condoms, then people will probably take more chances than they

would if they weren’t using condoms. Again, this seems to be

counterintuitive.

Mr. SHAYS. One last question. I heard the data is 85 percent; is

that because they’re not used properly?

Dr. GREEN. 85 percent is about right.

Mr. SHAYS. Basically, what you’re saying is so someone is having

sex with someone who had AIDS, by one out of ten, you’re going

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to get AIDS even with a condom. But is that because they’re not

being used properly?

Dr. GREEN. We don’t know the reasons. It’s probably more improper use. It’s not being consistent; this is when condoms are used

consistently, it’s probably that they’re not used correctly. In poor

countries, you don’t have good storage, condoms may be the wrong

size. How often in Africa I see condoms made in Thailand, wrong

size. There’s product failure, in part, because they may be old

condoms, expired and so forth, especially in poor countries.

So those reasons are—those figures are pretty consistent every

time. We knew this from family planning. Before the AIDS pandemic I worked in family planning; the condom was not one of the

more effective methods of prevention——

Mr. SHAYS. Let me do this; if any of the panelists want to just

respond to any question I asked Dr. Green.

Dr. NKYA. Mr. Chairman, I would like to comment. I would like

to ask him, at that particular time when condom distribution was

started, was there a survey, you know, a serological test to know

who was positive and who was negative? Because when you start

giving condoms, you don’t know who’s positive or who’s negative.

So when you started giving condoms, that’s the majority of those

people are already infected, but we are preventing infection. So

that is my concern.

And another thing about the storage, and the condoms being

made in Thailand being shorter than, you know, the private parts

of men in Africa it is true, but that is another aberration which I’m

seeing that if someone wants to give us assistance and he goes

ahead and orders condoms for us without taking into consideration

of sizes of our people, that is another thing that I’m saying that

I disagree with completely.

The storage part of it, you know, you give the condoms. You don’t

give money for logistic support whereby you could be able to transport and store the condoms in the situation whereby they remain,

you know, protective, that is another problem, because someone

says I’m giving you condoms, I’m ordering them, not to take into

consideration about the sizes, the needs and other logistical support which is needed to transport the condoms from where it is

manufactured, and to the end point to where, you know, the beneficiary is. That is another problem. And that’s why I support the

idea that the developing countries should be given the opportunity

to plan how to use the PEPFAR funds whenever the funds are

available.

Mr. SHAYS. Let me go to Ms. Lee. Oh, I’m sorry——

Dr. GAYLE. I was just going to make an additional comment. I

agree with the comment that was made about the shortcomings of

the survey which are cross-sectional data, and I think it needs to

be put into broader context. It could be that people with condoms

were already infected, it could be that by definition, those in the

population are already at greater risk, so it’s not surprising that

the rates would be higher, but I think what it really points to is

the fact of what we’ve been talking about, that it isn’t one or the

other, even condom use needs to be in concert with a focus on

changing risk behavior to begin with. And I think most people in

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inforce each other, and it’s not just a condom message, it’s a

condom message that also talks about reducing risk behavior, reducing the number of partners. And it’s by doing all of those things

together that you have the greatest impact and are synergistic.

So it is not one or the other, and that’s, again, why this whole

focus on being able to have a comprehensive approach can’t be said

enough.

Mr. SHAYS. Thank you. Did you want to say something?

Dr. GREEN. Yes.That last statement I completely agree with.

Mr. SHAYS. Thank you.

Ms. Lee.

Ms. LEE. Thank you, Mr. Chairman. I’m not sure who to direct

this question to, so whoever can answer it, please do.

Let me ask you this; with regard to the guidance document, abstinence or return to abstinence must be the primary message that

youth receive or for youth in PEPFAR countries, and information

about consistent and correct condom use is only provided to youth

who are identified as those who engage in risky behavior. But I

want to ask you just from a practical point of view, in a classroom

setting, how do you distinguish between youth who are engaged in

risky sexual behaviors and those who are not? And doesn’t it make

sense to provide again age-appropriate, scientifically medically

sound information that includes all aspects of ABC without stigmatizing or segmenting part of that message? And so how is that

addressed at this point? Dr. Gayle or Dr. Gootnick.

Dr. GAYLE. I would just agree that I think that the ability to provide the complete message as appropriate at a given age is a—

seems to me be more effective than segmenting information by age

group. I think that most of us would agree that we would want to

have young people abstain from sex as long as possible and that

would be desirable. But when you’re looking at a population of

young people, it is difficult to segregate information based on

whether or not somebody’s currently abstaining from sex or not.

And so having half information, not complete information, seems to

be a less effective approach than looking at what’s an age-appropriate way of giving people more complete information because

somebody who is sexually inactive and are abstaining 1 day may

become sexually active the next day, and we want them to have the

information that allows them to reduce their risk even if they’re

not totally avoiding risk. So I think the ability to do that in a comprehensive way at any age would be desirable.

Ms. LEE. So how is one supposed to separate out youth who are

high-risk youth in terms of youth who engage in risky sexual behavior being the ones who get the information with regard to correct and consistent condom use versus those who are not identified?

Dr. GAYLE. I think that raises a good point. I think it’s difficult.

I think it is easier for a group of youth who are at risk and who

are currently sexually active to know that. I think it’s difficult in

a situation of youth who are not specifically at high risk who are

in a classroom setting, who are within a civic organization or other

settings where there is going to be a mix of young people, to be

able to segregate information accordingly in a practical sense.

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Dr. NKYA. I would like to add on that. You know, for me, according to my experience, 20 years of working with AIDS, I have come

to discover that all young people are at risk. So trying to segregate

who is to get it is going to bring some problems. I think our message here should be that we should target all the youth, whether

in school or out of school, give them the message and correct information. And more probably, try to make sure that every child has

the right health information because the survey which was conducted in Dar es Salaam in high schools in Dar es Salaam, in 1988,

zero percent of the girls were infected with HIV, and then only one

boy was found to be infected because of transfusion.

Two years later, the infection went up 10 times, it was 8 percent.

That means that there is a high, you know, sexual activity taking

place among schoolgirls, especially where poverty is a problem.

So we should target the girls together with the boys, although

the infection with the boys was not significant, but we should target all the children, even as young as, you know, in primary one,

to tell them that there is AIDS, do you know AIDS, and then we

start from there. And make it a sustainable program, not just a

one-time seminar in school and then you disappear. So that is my

concern there.

So that is my concern there, a sustainable program from, you

know, primary 1, up to university if it is possible.

Ms. LEE. Thank you very much. I hope the powers that be heard

you, Doctor, because I think you make a lot of sense and it makes

sense. And, to me, listening to you, I am trying to, again, figure out

why the guidance documents instruct—you know, in PEPFAR

countries—instruct organizations to have the primary message as

being abstinence only, except the youth that they think are identified are at risk in terms of risky behavior.

Doctor Gootnick.

Dr. GOOTNICK. I would say briefly that the guidance document

we refer to is used extensively by the program officials in the field

and it is valued by them. They cite 3 key issues and key areas

where this guidance may be indeed—although clear if you read it

word for word—hard to apply in the field; one of which is the case

that you mentioned, the issue of how to deal with youth of different

age. There are different messages that can’t under PEPFAR’s guidance be offered to youths less than 14, youths who are older than

14, populations who may be at risk or most at risk, and as a practical matter it is difficult for them to apply the guidance.

The second area of confusion is permissible activity with respect

to condom use. There is guidance for different populations that allows you to discuss condoms but not promote condoms, and that becomes very difficult for the program officials to apply in the field.

And the third area where there is some confusion is in high-risk

activities or individuals. There is certain programs that PEPFAR

may implement for high-risk or most-at-risk populations, but in a

generalized epidemic it is often very difficult to determine who indeed is high risk or most at risk, because the fairest way to define

that is almost anybody who is having sex outside of a known mutually monogamous relationship with a noninfected partner or someone who is abstinent.

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Dr. GREEN. If we go by data, the epidemiologic data, we see that

7.2 percent of subSaharan Africans, if you average all the countries

together in subSaharan Africa, about 7 percent of Africans are HIV

positive, which means 93 percent are not positive. You don’t agree?

Mr. SHAYS. I was shaking my head because I was thinking 7 percent of a population is such a huge number. It blows me away.

Dr. GREEN. Yes it is way too high.

Mr. SHAYS. I think of kids going to school with no teachers, coming home to no parent.

Dr. GREEN. I mention that as an antidote to the thinking that

everyone is a current risk and all African men are promiscuous and

all African women have no power—African women have more

power than we foreigners give them credit for.

I agree with most of the comments I just heard, Dr. Nkya. I feel

certain that if we had time to sit down and if you just interviewed

me and Dr. Nkya and try to find points of disagreement, there

wouldn’t be many. And if Africans could choose for themselves,

without being influenced by what is on the donor menu not only

from the U.S. Government but from the United Nations, AID, and

other organizations I think that would be ideal.

I see a lot of of these problems as growing pains. It is as if we

were putting billions of dollars into reducing lung cancer and we

for some reason, because it might hurt people’s feelings, we didn’t

have don’t start smoking or give up smoking if you are already

smoking or at least smoke fewer cigarettes per day.

And I have never said that condoms were the only message, but

it was the main message before PEPFAR, and the other interventions were and are for all other major donors treating STDs, VCT,

voluntary counseling and testing, and treating HIV-infected mothers with nevirapine. And I think it is a great step forward that the

U.S. Government for whatever reasons, maybe it was for, I don’t

know, ideological reasons—Congresswoman Lee, you said you were

in on the planning of PEPFAR so maybe you know, but I don’t

know what the reasons were, but I think it was a genuine positive

step forward to include primary prevention, avoid the risk altogether if you can.

But here are the other things you can do if that is not possible.

And I think programs should be integrated and not compartmentalized, and if some people in the field are having problems because

of the way the earmark is written, nobody likes earmarks. I come

from 2 generations of foreign service officers. My father and grandfather always complained about congressional earmarks. I sympathize, but I think it has brought us forward.

Mr. SHAYS. Let me quickly get a quick response. I am surprised

that other countries aren’t doing more. And am I just misreading

it? I am surprised that other countries aren’t doing more, and am

I misreading what other countries are doing, No. 1? And I am also

told sometimes when the United States really steps up to the plate,

other countries feel they don’t have to.

And so, one, is the United States stepping up to the plate, even

if we had this disagreement about where one-third of the prevention dollars go? And No. 2, are other countries doing what they

should do? Maybe, Dr. Gayle, I could just ask you that, and Dr.

Gootnick.

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Dr. GAYLE. Definitely the United States is stepping up to the

plate, and, as the earlier panel said, we fund anywhere from onethird to one-half depending on how the numbers come out in terms

of funding. I think the difference is that the U.S. Government has

always had a strong bilateral program where other countries have

not, and more of the countries put their money through the pooled

resources, through the global fund. So I think there are a variety

of different ways of looking at funding, and a lot of the other countries also put their money either in the global fund or through programs that are not specific sectorial programs and are going to

much more combined funding approach where they put it into a

pool that then gets used, so it is harder to track it as AIDS funding.

That being the case, clearly the U.S. Government is the largest

funder of HIV programs, and the work needs to be done to continue

to encourage others to increase their resources.

Mr. SHAYS. Quickly, what is the close second? Maybe there isn’t

a close second. Who is second?

Dr. GAYLE. England.

Mr. SHAYS. There is certainly not a close second. We take a lot

of hits on a lot of things but sometimes we don’t pat ourself on the

back.

Dr. GAYLE. I think we should pat ourselves on the back. I also

think we have to remember that we are the largest economy, and

when you start looking at our contribution per capita, we don’t

have quite as much to be proud of; we still should be proud and

we still are the largest contributor, but in terms of per capita funding, if you look at some of the smaller countries per capita, they

actually are contributing substantial amounts. So I think we need

to look at it in a variety of different ways.

Mr. SHAYS. Fair enough. Dr. Gootnick.

Dr. GOOTNICK. Just to put a couple of numbers to those comments, and while not the subject of our analysis, roughly speaking

it is estimated about $8.3 billion was spent on AIDS last year, global spending. About $2.5 billion of that was national spending,

spending by the Governments of Tanzania, the so-called recipient

nations. And the remainder of that would be donor spending. Of

that, OGAC was more than half, about $3.2 billion, with the rest

of the two nations combined somewhere in the $2.5 to $2.7 billion

range.

Mr. SHAYS. That would suggest our economy at 25 percent of the

world’s economy, we are doing 50 percent of the contributions.

Dr. GOOTNICK. Yes. The other way to look at it is to look at the

percentage, our share of GDP. There is an aspirational notion that

donor countries would provide .7 percent of their GDP for development assistance, humanitarian assistance, broadly speaking. Some

countries in Europe get closer to that and a few reach it. The

United States is about at .1 percent of GDP.

Mr. SHAYS. Let me do this. Is there any closing comment that

any of you would like to make, something that we should have

brought up that we didn’t, something that needs to be put on the

record? And we will start with you, Dr. Green.

Dr. GREEN. Just to continue the answer to that question, but it

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cerned about the amounts or even the proportions of money; rather,

that money is well spent. Daniel Lobier, formerly of Cambridge

University, now with the Global Fund for ATM, estimated that between 1986 and 1991 in Uganda, when Uganda turned that epidemic around using its own approach before we donors really

moved in there, it was before the U.S. aid, the first bilateral program, Uganda spent about 25 cents per person per year for this

highly effective program. It was the first really effective program

in the world.

So if money is well spent, we—it is less an issue of how much

and—but the other important point I would like to leave the subcommittee with is that there is a perception out there that ABC is

something to do with the Bush administration, and like a faithbased initiative and something to appease the religious right. And

for that reason the major donors, United Nations, AID, WHO, all

the major bilateral multilateral donors pretty much are very suspicious of it and don’t support the A and B parts, by and large, and

that is what the government panel said.

Mr. SHAYS. Very interesting. Dr. Gootnick.

Dr. GOOTNICK. Just briefly to reiterate what GAO recommended

in the aftermath of this study was that Congress—that the Office

of Global AIDS Coordinator collect and report information on the

downstream implications of the spending requirement report it to

Congress, and that Congress use it in its ongoing oversight of the

program. And we reiterate that recommendation.

Mr. SHAYS. Thank you for doing that. Dr. Gayle.

Dr. GAYLE. Yes, three very brief points, I think this panel is the

first one where all agree that the ABC approach is important and

should be the cornerstone of behavioral prevention. I think where

we disagree is how do we get to that comprehensive approach.

And I would just like to somewhat differ with some of the comments that before the PEPFAR program there was not a commitment to comprehensive programming. Having run USAIDS prevention programs from the very early days, CDC’s programs, that in

fact the U.S. Government strategy was behavior change, treatment

of STDs and condoms before the PEPFAR. So the idea that the—

only by having that earmark will we make—keep a commitment to

comprehensive prevention doesn’t speak to the facts that a comprehensive approach that includes behavior change, has been part

of the U.S. Government program for the last couple of decades.

Second, I think that the issues that have been raised that there

needs to be greater flexibility to integrate programs that focus on

the other dimensions, the vulnerability that people face, the poverty, gender inequity, food insecurity, that the other issues that put

people at risk for HIV to begin with, particularly women, need to

be able to be addressed, perhaps not directly through resources

from PEPFAR, but a greater flexibility and much greater coordination of U.S. Government funding, so that in fact there is the ability

to knit together these other aspects that, after all, if we don’t attack the context in which people’s behaviors occur, we are not going

to be able to change individual behavior, because it is often based

on just life survival. And so we have to be cognizant of those issues.

And, third, that the importance of a long-term commitment to

sustainability, many of the programs that we are involved in, the

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aspects that would allow for community buy-in and long-term sustainability are not allowed, and that we have to recognize that if

we are going to commit to these programs being sustainable in the

future, we have to look at how we do that and how do we make

sure that there is community buy-in, there is capacity development,

and that these things go hand in hand with the immediate need

to get programs up and running.

Mr. SHAYS. Thank you.

Dr. Sawere Nkya, you have the last word——

Dr. NKYA. Mr. Chairman.

Mr. SHAYS [continuing]. Before I get the last word.

Dr. NKYA. I am the last word at home, too.

Mr. Chairman, I totally agree with what, you know, my fellow

testimony givers have talked about. But I would like to emphasize

on flexibility and just bring to attention that, you know, empowering women in developing countries is through education. If women

are not educated we will never, ever be able to empower them and

they will always remain as vulnerable. So probably if there could

be some way whereby countries are made accountable into promoting women or female education, like giving them free education,

giving free primary school education, because it makes a difference

if you are educated or not.

And another thing is that of, you know, trying to remove the

component of compartmenting people as risky groups or non-risky

groups because that is stigmatizing them. It makes people, even if

they know they are at risk, they never go for anything to help them

preserve life, because here we are talking about preserving life and

as a result also promoting the economies of the developing countries through reduction of morbidity and mortality.

So, Mr. Chairman, I request for flexibility and probably a change

of direction of looking into all countries’ needs; specifically, you

know, to that country, not, you know, the comparison with another

country.

Mr. Chairman, thank you very much.

Mr. SHAYS. Thank you very much. And we should pay attention

to you. You came all the way, 6,000 miles, to tell us this, and you

have been doing this work for decades.

You are a true hero, a true hero, and we really value your testimony. We value the testimony of all our panelists but I particularly

want to thank you.

Mrs. Lee, a comment to close.

Ms. LEE. I want to say, Mr. Chairman, thank you for your leadership and for your commitment to address this entire issue in a

bipartisan way and in a way that makes sense and it works; because, as I said earlier, this is about saving lives and it is about

making sure that people who are living with HIV and AIDS can

live longer.

I want to thank all of our panelists. Whether we agree or disagree, I think we have to muddle through all of this together because it is so serious.

And the United States must continue to be out front in terms of

leadership, in terms of resources, and in terms of really being committed to allowing countries to do their thing in the way that they

know how to do it best. And so I hope that we can get to that point

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where we can go back when we do reauthorize PEPFAR, look at

your testimony, the suggestions you have made, and try to figure

out how we can incorporate some of these very thoughtful suggestions and ideas into what we have to come up with in the future.

So thank you again, Mr. Chairman.

Mr. SHAYS. Thank you. I just want to say you are the true leader

on this. I eat the crumbs off your table. I thank you for what you

have done, and thank you for participating in this hearing and,

again, thank both panels, our first and second panel, and just to

say to Planned Parenthood that enabled me to take a really good

look at what two countries were doing. I went with the expectation

I would come back somewhat, frankly, disheartened, and I came

back with a tremendous amount of gratitude for the spirit that I

saw in both Tanzania and Uganda, particularly among the young

people that I met. I thought this is an alive place. And I met so

many young kids who just want to have a better future, that were

excited about their future, not asking for a lot.

And it made me feel—and I met a lot of people who are running

great programs.

So I came back from my visit to Africa with a feeling that it has

such unbelievable potential.

And I just kind of feel that Africa is on the cusp, at least in the

two countries that I saw, of really turning around, not just their

concerns with AIDS, but a whole host of other issues. So I thank

you. And with that, we will adjourn.

Thank you very much.

[Whereupon, at 4:22 p.m., the subcommittee was adjourned.]

[The prepared statement of Hon. Dennis J. Kucinich and additional information submitted for the hearing record follows:]

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