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PEPFAR: FROM EMERGENCY TO SUSTAINABILITY

AND ADVANCES AGAINST HIV/AIDS

HEARING

BEFORE THE

COMMITTEE ON FOREIGN AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED ELEVENTH CONGRESS

SECOND SESSION

SEPTEMBER 29, 2010

Serial No. 111–129

Printed for the use of the Committee on Foreign Affairs

(

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

(II)

COMMITTEE ON FOREIGN AFFAIRS 

HOWARD L. BERMAN, California, Chairman 

GARY L. ACKERMAN, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

DONALD M. PAYNE, New Jersey 

BRAD SHERMAN, California 

ELIOT L. ENGEL, New York 

BILL DELAHUNT, Massachusetts 

GREGORY W. MEEKS, New York 

DIANE E. WATSON, California 

RUSS CARNAHAN, Missouri 

ALBIO SIRES, New Jersey 

GERALD E. CONNOLLY, Virginia 

MICHAEL E. MCMAHON, New York 

THEODORE E. DEUTCH, Florida 

JOHN S. TANNER, Tennessee 

GENE GREEN, Texas 

LYNN WOOLSEY, California 

SHEILA JACKSON LEE, Texas 

BARBARA LEE, California 

SHELLEY BERKLEY, Nevada 

JOSEPH CROWLEY, New York 

MIKE ROSS, Arkansas 

BRAD MILLER, North Carolina 

DAVID SCOTT, Georgia 

JIM COSTA, California 

KEITH ELLISON, Minnesota 

GABRIELLE GIFFORDS, Arizona 

RON KLEIN, Florida 

ILEANA ROS-LEHTINEN, Florida 

CHRISTOPHER H. SMITH, New Jersey 

DAN BURTON, Indiana 

ELTON GALLEGLY, California 

DANA ROHRABACHER, California 

DONALD A. MANZULLO, Illinois 

EDWARD R. ROYCE, California 

RON PAUL, Texas 

JEFF FLAKE, Arizona 

MIKE PENCE, Indiana 

JOE WILSON, South Carolina 

JOHN BOOZMAN, Arkansas 

J. GRESHAM BARRETT, South Carolina 

CONNIE MACK, Florida 

JEFF FORTENBERRY, Nebraska 

MICHAEL T. MCCAUL, Texas 

TED POE, Texas 

BOB INGLIS, South Carolina 

GUS BILIRAKIS, Florida 

RICHARD J. KESSLER, Staff Director 

YLEEM POBLETE, Republican Staff Director 

(III)

C O N T E N T S 

Page

WITNESSES 

The Honorable Eric Goosby, United States Global AIDS Coordinator, U.S. 

Department of State ............................................................................................ 8

Thomas R. Frieden, M.D., M.P.H., Director, Centers for Disease Control and 

Prevention, and, Administrator, Agency for Toxic Substances & Disease 

Registry ................................................................................................................. 19

Anthony S. Fauci, M.D., Director, National Institute of Allergy and Infectious 

Diseases (NIAID), National Institutes of Health .............................................. 37

Ms. Paula Akugizibwe, Advocacy Coordinator, AIDS and Rights Alliance for 

Southern Africa (ARASA) .................................................................................... 72

Wafaa El-Sadr, M.D., M.P.H., Director, International Center for AIDS Care 

and Treatment Programs (ICAP), Mailman School of Public Health, Columbia University ....................................................................................................... 84

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

The Honorable Howard L. Berman, a Representative in Congress from the 

State of California, and Chairman, Committee on Foreign Affairs: Prepared 

statement .............................................................................................................. 3

The Honorable Eric Goosby: Prepared statement ................................................. 11

Thomas R. Frieden, M.D., M.P.H.: Prepared statement ...................................... 21

Anthony S. Fauci, M.D.: Prepared statement ....................................................... 39

Ms. Paula Akugizibwe: Prepared statement ......................................................... 76

Wafaa El-Sadr, M.D., M.P.H.: Prepared statement .............................................. 88

The Honorable Ileana Ros-Lehtinen, a Representative in Congress from the 

State of Florida: Prepared statement ................................................................. 96

APPENDIX 

Hearing notice .......................................................................................................... 104

Hearing minutes ...................................................................................................... 105

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

State of New Jersey: Prepared statement .......................................................... 106

The Honorable Russ Carnahan, a Representative in Congress from the State 

of Missouri: Prepared statement ......................................................................... 108

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

State of Texas: Prepared statement ................................................................... 110

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

the State of New Jersey: Material submitted for the record ............................ 117

Written responses from the Honorable Eric Goosby, Thomas R. Frieden, M.D., 

M.P.H. and Anthony S. Fauci, M.D., to questions submitted for the record 

by the Honorable Russ Carnahan ....................................................................... 132

Written responses from the Honorable Eric Goosby, Thomas R. Frieden, M.D., 

M.P.H. and Anthony S. Fauci, M.D., to questions submitted for the record 

by the Honorable Barbara Lee, a Representative in Congress from the 

State of California ................................................................................................ 135

(1)

PEPFAR: FROM EMERGENCY TO SUSTAINABILITY AND ADVANCES AGAINST HIV/AIDS 

WEDNESDAY, SEPTEMBER 29, 2010

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

The committee met, pursuant to notice, at 9:40 a.m., in room 

2172, Rayburn House Office Building, Hon. Howard L. Berman 

(chairman of the committee) presiding. 

Chairman BERMAN. The hearing will come to order. We are going 

to be joined very soon by my friend from New Jersey Mr. Smith, 

and he is okay with us starting the hearing. In a moment I will 

recognize myself and then Mr. Smith for up to 7 minutes each for 

the purpose of making an opening statement. 

The chair and ranking member of the Africa and Global Health 

Subcommittee aren’t here, and Mr. Payne probably won’t be able 

to get here until 10 o’clock or so, so if the other members here want 

to make a 1-minute opening statement, you are welcome to do so. 

I know you are both very interested in this subject. 

The purpose of today’s hearing is to review the progress PEPFAR 

has made toward reversing the global threat posed by the AIDS 

pandemic and how those efforts have set the stage to transform 

PEPFAR from an emergency initiative to a sustainable program. 

This morning, we are going to hear about some outstanding 

achievements and promising research that gives hope for increasing our ability to reverse the spread of the disease. We also will 

hear about the challenges we still face if we are to accomplish the 

ambitious goals set forth in the Tom Lantos and Henry J. Hyde 

United States Global Leadership Against HIV/AIDS, Tuberculosis 

and Malaria Reauthorization Act of 2008. 

This legislation, which built on the successes of the original legislation, the U.S. Leadership Against HIV/AIDS, Tuberculosis and 

Malaria Act of 2003, is a prime example of the bipartisan support 

that exists to fight the global HIV/AIDS pandemic. The fact that 

both sides joined together to bring positive change demonstrates 

that saving lives around the world is not a Republican or Democratic issue. It is a priority that all Americans share. 

PEPFAR faced many challenges during its first 5 years, including weak health care delivery systems, poor infrastructure, expensive and unavailable drugs, and limited workforce. These factors 

kept millions infected with the disease isolated from the care and 

treatment they needed. 

Social barriers like stigma, gender inequality, and prejudices 

against men-who-have-sex with men, commercial sex workers, and 

2

intravenous drug users, compounded the challenges to expanding 

services to those in need. 

But PEPFAR successfully invested in strengthening health care 

systems, training new health care personnel, purchasing affordable 

drugs, and helped to remove stigma and empower women and girls 

and other at-risk populations. 

In the face of controversy and our own economic challenges, Congress remained unified behind a single humanitarian purpose. 

Even in the face of our differences, we never lost sight of the goal 

to save the lives of millions of poor human beings who do not have 

the resources and means to save themselves and prevent the 

spread of AIDS. 

In preventing the spread of AIDS, we are not simply achieving 

the humanitarian objective of saving lives and preventing suffering. We also are advancing economic growth and building democratic stability by preserving the health of productive citizens, enabling people to support their families and contribute to the economic, social and political life of their communities. 

Last week the United Nations General Assembly convened a 

summit to discuss progress to date on achieving the Millennium 

Development Goals. Addressing the AIDS pandemic has had an impact across all of the MDGs. We must ensure that our commitment 

to fighting AIDS is designed to reinforce other critical health and 

developmental priorities. 

Today we have some good news in spite of the sobering impact 

the pandemic continues to have in poor countries. Globally, the 

overall rate of new HIV infections has slowed and prevalence rates 

have leveled off. According to the 2009 UNAIDS report, new HIV 

infections have been reduced by 17 percent over the past 8 years. 

In 2008, sub-Saharan Africa reported 14 percent fewer new infections than in 2001. In East Asia, new HIV infections declined by 

nearly 25 percent and in South and Southeast Asia they declined 

by 10 percent. 

Scientists from the U.S. and Africa are conducting research on 

the use of anti-retroviral drug treatment as part of prevention. Preliminary results demonstrated that ARVs could both keep a people 

well and prevent infections. For example, in Africa, a seven-country 

study was undertaken in which one partner was infected and the 

other was not. After 3 years, only one uninfected partner was HIVpositive when the infected partner was on an antiretroviral therapy. And in South Africa, researchers recently identified a new 

microbicide that may significantly reduce HIV infection rates in 

women. 

Based on these and other promising developments, it is fair to 

conclude that our ambitious investment in AIDS prevention, treatment and care programs has helped make an historical difference 

and there is sufficient epidemiological evidence to give us hope that 

this scourge on humankind can be defeated within our lifetime. 

While there is good news to report, we can’t forget about the 

sheer magnitude of the epidemic. We still have 33.4 million people 

living with HIV worldwide and only 42 percent of those in need of 

treatment have access. Two-point-seven million people were newly 

infected in 2008, 14 million children in Africa have been orphaned 

3

by AIDS and around 430,000 children are born with HIV each 

year. 

U.S. global leadership has been extremely important in the fight 

against HIV/AIDS. President Obama, like President Bush before 

him, has made it clear the U.S. has a moral commitment to combat 

this deadly disease. We owe it to ourselves and our fellow Americans to ensure that we live up to these commitments, enshrined in 

law and policy. To that end, we must continue to strengthen our 

work with other bilateral donors, multilateral institutions, recipient countries, and local and international NGOs. 

[The prepared statement of Mr. Berman follows:]


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Chairman BERMAN. We have two very distinguished panels of 

witnesses here today to discuss these important issues. I look forward to hearing their testimony. Before I turn it over to Mr. Smith, 

who has done a tremendous amount on this issue, I do want to acknowledge and welcome the presence of a number of women members of Parliament from 12 African countries, including the Deputy 

Prime Minister of Zimbabwe, the Honorable Khupe. Thank you 

very much for being here, and we welcome you. 

Now I am pleased to yield to the gentleman from New Jersey for 

any remarks he may like to make. 

Mr. SMITH. Thank you very much, Mr. Chairman, for holding 

this very important hearing on the President’s Emergency Plan for 

AIDS Relief. I want to thank you and your predecessor Tom Lantos, and certainly Congressman Henry Hyde, both who chaired this 

committee, like you, who were very, very aggressive in promoting 

this program as well as the legislation. 

President George W. Bush described in his 2003 State of the 

Union Address how hospitals in rural South Africa were telling 

people, ‘‘You have got AIDS, we can’t help you, go home and die.’’ 

President Bush committed the United States to assist African 

countries in overcoming the HIV/AIDS scourge not only with substantial resources, but also by achieving specific goals with measurable targets. And this effort was to be undertaken in countries that 

for the most part had poor health infrastructures, a sick and dying 

health care workforce, and other daunting obstacles. Many said it 

couldn’t be done. PEPFAR proved them wrong. 

Working with the President, Congress passed the United States 

Leadership against HIV/AIDS, Tuberculosis and Malaria Act. 

Thanks to strong continued bipartisan support, PEPFAR can now 

boast about directly treating over 2.4 million people with lifesaving 


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antiretroviral drugs. Nearly 340,000 babies born to HIV-positive 

mothers were born HIV free thanks to PEPFAR prevention of 

mother-to-child transmission programs. Almost 11 million people 

affected by HIV/AIDS have received care, including 3.6 million orphans and vulnerable children. And in Fiscal Year 2009 alone, 29 

million people were counseled and tested for HIV thanks to 

PEPFAR. 

Despite these successes I would like to highlight several concerns. One is the administration’s implementation of PEPFAR as 

part of the new Global Health Initiative, of which PEPFAR is the 

major component, in the absence of authorizing legislation. I understand the administration intends through the Global Health Initiative to change the way the U.S. Government conducts its foreign 

assistance in this area at a fundamental level. I would strongly 

argue that such a change requires legislative authorization, given 

the amount of taxpayer money and important policies that are at 

stake. 

Another major concern is GHI’s emphasis on integrating 

HIV/AIDS programming with family planning as well as various 

health programs. This is being undertaken in the context of a family-planning program, which, due to President Obama’s rescission 

of the Mexico City policy, now includes foreign nongovernmental 

organizations that provide, support and seek the expansion of access to abortion. When one considers that this involves over $715 

million in family-planning funding under the Fiscal Year 2011 proposed budget, the ability for abortion groups to leverage this funding in relation to U.S. HIV/AIDS funding under the GHI is deeply 

disturbing. 

Furthermore, it now appears that the considerable sums that the 

United States contributes to the Global Fund to Fight AIDS, TB 

and Malaria—$1 billion in Fiscal Year 2010—may contribute to a 

new Global Fund initiative to fund abortions. This possible intervention, part of the Global Fund’s effort to contribute to the Millennium Development Goals, is described in a document presented to 

the Global Fund Board at its meeting in April of this year. This 

paper is intended to facilitate the Board’s discussion of the Fund’s 

role as a ‘‘strategic investor in maternal and child health.’’ It asserts that the Global Fund will optimize—this is a quote—‘‘existing 

interventions to improve the health outcomes for women and children’’ by identifying areas for greater integration of HIV, TB and 

malaria services with ‘‘sexual and reproductive health services.’’ In 

the chart identifying ‘‘interventions that could be supported with 

the new funding,’’ the paper explicitly proposes abortion. 

Abortion, I would say to my colleagues and to our distinguished 

panelists, is by definition infant mortality, and it undermines the 

achievement of the fourth millennium goal. There is nothing, nothing benign or compassionate about procedures that dismember, poison, induce premature labor or starve to death a child. Indeed the 

misleading term ‘‘safe abortion’’ misses the point that abortion, all 

abortion, legal or illegal, is unsafe for the child, and all is fraught 

with negative health consequences, including emotional and psychological damage, for the mother. 

Monies that the U.S. contributes to the Global Fund are ultimately taxpayer dollars, and polls show that 61 percent of U.S. taxVerDate 0ct 09 2002 16:08 Dec 09, 2010 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 F:\WORK\FULL\092910\61515 HFA PsN: SHIRL
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payers do not want government funding paying for abortions. Our 

U.S. delegation should keep this in mind as it takes up this question with the rest of the Board at the next meeting in December. 

And finally, one final concern is the importance of not only including but also reaching out to faith-based organizations in all of 

our global health programming. Given studies that show up to 70 

percent of health care in Africa—and that is a WHO number—is 

provided by faith-based hospitals, clinics and organizations, it is 

imperative for the continued success of PEPFAR to have them as 

a primary partner. Thus I would hope that the administration is 

assisting local governments in developing strategies that include 

faith-based networks as an integral part of their health system. 

Their effort also necessitates respect for the conscience clause provisions contained in the Leadership Act and reaffirmed and 

strengthened by this committee and by this House and the Senate 

in the 2008 reauthorization. 

Mr. Chairman, I look forward to our distinguished panelists’ 

comments, and I thank you for yielding. 

The gentleman has yielded back his remaining time, and for 1-

minute opening statements any members of the committee? 

Ambassador Watson, are you——

Ms. WATSON. I was going to defer to Barbara Lee. 

Chairman BERMAN. The gentlelady from California has deferred 

to the gentlelady from California. 

Ms. LEE. Thank you again, Congresswoman Watson. 

Thank you again, Chairman Berman, for this hearing. Thank all 

of you for being here and specifically for the work that you do each 

and every day to save lives. 

I, of course, as you know, helped write the initial PEPFAR with 

Chairman Hyde, and we sorted through many of these issues that 

have been raised by Congressman Smith, and believe you me, I believed then as I believe now the countries should be able to determine their own plan. However, we didn’t win that one, and we 

know for a fact that PEPFAR funds are not used for abortions. I 

have been out many times, as have members of this committee, so 

I thought we had settled that, not to my satisfaction, but I thought 

we had settled it. 

Secondly, let me just say I did participate recently at the International AIDS Conference in Vienna, and I know there is a lot of 

concern about the extent of our commitment to fighting this disease. The global economic crisis has seemed to have dried up in 

many quarters, the political will and the resources. Yet here in our 

own country we know that the drive for military spending to build 

new and even more deadly weapons systems, this debate continues 

to go unabated. 

And so I think we need to really focus on how we can move forward with PEPFAR, with the International AIDS Conference coming to Washington, D.C., in 2012. I hope we can show the world 

that the United States is seriously committed to fighting this pandemic, and to setting our goal of an AIDS-free generation, and to 

use PEPFAR as an example for our own domestic strategy here in 

America. 

Thank you again, Mr. Chairman. 

7

Chairman BERMAN. Thank you. And just before that I do want 

to—Ms. Lee’s opening comments reminded me that in the very beginning of all this back in 2001, 2002, she was a driving force to 

the initial legislation. 

Ambassador Watson. 

Ms. WATSON. Yes. Good morning, Mr. Chairman, and I want to 

thank you for holding this timely hearing on PEPFAR and the advances against HIV/AIDS. I concur with the two of you, Ms. Lee 

and the chair. 

Currently 33.4 million people are living with HIV and AIDS 

worldwide, with 2.7 million new infections in the year 2008. 

Through President Bush’s PEPFAR initiative, it has made great 

strides in responding to the emergency of the global pandemic, and 

we must now look to create a substantial approach to confronting 

HIV/AIDS. 

President Obama’s 5-year strategy aims to achieve just that. Unfortunately, it is unclear how we will transition to a country-owned, 

sustainable health system in struggling nations that will be able to 

respond to the plethora of diseases that plague the developing 

world. I look forward to hearing from the administration about how 

this transition will take place. 

So I want to yield back and thank you, Mr. Chairman. 

Chairman BERMAN. The time of the gentlelady is expired. 

Anyone else seek recognition for an opening statement? The 

gentlelady from California. 

Ms. WOOLSEY. What would you do without us, Mr. Chairman? 

Chairman BERMAN. I wouldn’t be here. 

Mr. WOOLSEY. The women from California. That is true. 

Thank you all for being here, and I am looking forward to your 

testimony. 

I have to apologize. We will be in and out because of other 

things. But I am really interested in hearing how you are integrating HIV/AIDS treatment and prevention with a larger role of 

women’s health and maternal health. I think that pulling all of this 

together into one conversation is very, very important. Are we getting more bang for our buck with PEPFAR by doing this? And are 

women getting health care in a one-stop shop style? 

So I am just looking forward to hearing all of that from you, and 

I thank you for all you know and all you do for PEPFAR. Thank 

you very much. 

Chairman BERMAN. The time of the gentlelady has expired. Any 

other members seeking recognition for an opening statement? If 

not, it is my pleasure now to introduce our first panel. 

It is an amazing logistical feat that the three of you could actually get together in terms of your calendars and ours to be here, 

and we are very grateful that you are. 

Ambassador Eric Goosby serves as United States Global AIDS 

Coordinator. In this capacity Ambassador Goosby oversees implementation of the U.S. President’s Emergency Plan for AIDS Relief—that is the PEPFAR program—and leads all U.S. Government 

international HIV/AIDS efforts, including engagement with the 

Global Fund to fight AIDS, tuberculosis and malaria. Ambassador 

Goosby has over 25 years of experience developing health care delivery systems, served as the first director of the Ryan White Care 

8

Act at the U.S. Department of Health and Human Services, and I 

believe has a California connection. 

Dr. Thomas Frieden became director of the Centers for Disease 

Control and Prevention and administrator of the Agency for Toxic 

Substances and Disease Registry in June 2009. From 2002 to 2009, 

he served as a commissioner of the New York City Health Department, one of the world’s largest public health agencies. Dr. Frieden 

previously worked for CDC from 1990 to 2002, where he began his 

career as an epidemiologic intelligence service officer. 

Dr. Anthony Fauci was appointed director of the National Institute for Allergy and Infectious Diseases in 1984. He oversees an extensive research portfolio of basic and applied research to prevent, 

diagnose and treat infectious diseases such as HIV/AIDS and other 

sexually transmitted infections, influenza, tuberculosis, malaria, 

and potential agents of bioterrorism. Dr. Fauci is the recipient of 

numerous prestigious awards for his scientific accomplishments, including the Presidential Medal of Freedom and the National Medal 

of Science. 

Gentlemen, we are honored to have you here. 

Ambassador Goosby, why don’t you start? All of your prepared 

statement will be included in the record, and we will be grateful 

for you summarizing your main points. 

STATEMENT OF THE HONORABLE ERIC GOOSBY, UNITED 

STATES GLOBAL AIDS COORDINATOR, U.S. DEPARTMENT OF 

STATE 

Ambassador GOOSBY. Thank you very much, Chairman Berman, 

Ranking Member Ros-Lehtinen and members of the committee. 

Thank you for this opportunity to discuss the progress we have 

made under PEPFAR with your long-standing bipartisan support. 

I am pleased to be here with my friends and colleagues Dr. Tom 

Frieden and Dr. Tony Fauci. All of the agencies involved in 

PEPFAR contribute their strengths to a unified interagency effort 

that has maximized our impact. 

I serve with Dr. Frieden and Dr. Shah of USAID as the operations committee for President Obama’s Global Health Initiative. 

GHI builds on our shared interagency experience, and I appreciate 

the committee allowing us to speak to it and the commitment on 

all agencies’ parts to collaboration. 

I have been working on HIV/AIDS for almost 30 years. Five to 

six years ago those of us who engaged in HIV work in Africa saw 

daily tragedies on a vast scale. Yet today with American leadership, PEPFAR has brought about a dramatic transformation. 

I have outlined the results to date in my written testimony. With 

PEPFAR as its cornerstone, GHI will support coordinated interventions to increase our ability to save lives from AIDS and other challenges. With the support of this Congress and the Obama administration, the number of people receiving HIV prevention, treatment 

and care will continue to grow. In addition to doubling the number 

of babies born HIV-free, the United States will support the prevention of more than 12 million new HIV infections, HIV treatment for 

more than 4 million, and care for more than 12 million, including 

5 million orphans and vulnerable children. 

9

Our prevention, care and treatment programs are integrally 

linked. We have led the world in rapidly scaling up biomedical prevention, such as male circumcision and prevention of mother-tochild transmission. 

PEPFAR has also worked to reduce treatment costs and to expand service delivery. Reflecting a key GHI principle, we support 

operations research to identify innovations and best practices to 

save more lives. 

Simply put, our work has been and continues to be about saving 

lives as part of our shared global responsibility to make smart investments. Partnerships are an overarching principle for the Global 

Health Initiative. The United States provides nearly 60 percent of 

donor government funding for HIV/AIDS, a leadership role we are 

proud of and which, thanks to Congress’ reauthorization of 

PEPFAR, will continue. 

Yet the global need is a global responsibility and all have roles 

to play. An important mechanism for this is the Global Fund. The 

United States has been its largest donor, providing more than $5.1 

billion, and providing support for grant implementation at the 

country level that has proven crucial to ensuring the grants can deliver. 

As we implement PEPFAR’s 5-year strategy, let me highlight 

three priorities that reflect the GHI principles. First, saving more 

lives through PEPFAR activates our ability to focus on and be part 

of the Global Health Initiative. During its first phase PEPFAR focused on meeting ambitious goals for delivery of prevention, care 

and treatment. Moving forward, make no mistake, we will support 

expansion of these core services. 

Yet people affected by HIV are not defined by the virus alone. 

Like everyone else, they have a change and range of other health 

needs. That is why integration is a core GHI principle, and GHI 

will help to holistically address these needs. At the same time we 

also want to reach the clients of other programs, such as maternal 

and child health, with HIV interventions. For example, women who 

come to antenatal clinics are an ideal population for PMTCT programs. Integration under GHI offers the real opportunity of increasing our impact on health and, again, saving more lives. 

A second priority is addressing gender issues with HIV programming. GHI recognizes that focusing on women, girls and gender equity is a force multiplier benefiting women, their families and the 

communities. AIDS is the leading cause of death of women of reproductive age worldwide, and in Africa nearly 60 percent of those 

living with HIV are women. During its first phase PEPFAR began 

a five-point gender strategy seeding countries with small initiatives. We are now expanding them with a focus on PMTCT and 

country-led projects. 

One risk factor for HIV is the tragedy of gender-based violence. 

We are investing $30 million to combat it in three severely burdened countries, and in all countries we are supporting post-rape 

care, while also seeking to prevent sexual violence in the first 

place. Last week at the Clinton Global Initiative, we joined the Together for Girls public-private partnership to combat violence 

against girls. 

10

Lastly, we are focused on the GHI principle of expanding country 

ownership and local capacity to build a sustainable program. As we 

responded to the HIV emergency in the first phase of PEPFAR, we 

worked largely through international partners. A major priority we 

have now added is increasing the capacity of countries to manage, 

oversee and operate their health-delivery systems. 

Moving forward we will increasingly emphasize a third dimension, community empowerment. As we pursue support for health 

systems under GHI, we know local communities can ensure accountability in a way that outsiders never can. That feedback dialogue is essential for true sustainability. 

In conclusion, we are making great strides, but much work remains. We must keep our eyes on the prize, and that is to save 

more lives. I remain grateful for your ongoing support for this effort and look forward to the questioning. 

[The prepared statement of Ambassador Goosby follows:]

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Chairman BERMAN. Dr. Frieden. 

STATEMENT OF THOMAS R. FRIEDEN, M.D., M.P.H., DIRECTOR, 

CENTERS FOR DISEASE CONTROL AND PREVENTION, AND, 

ADMINISTRATOR, AGENCY FOR TOXIC SUBSTANCES & DISEASE REGISTRY 

Dr. FRIEDEN. Thank you very much. Good morning, Chairman 

Berman and Ranking Member Smith. It is a pleasure and an honor 

to be here along with my friends and colleagues, Dr. Goosby and 

Dr. Fauci. 

Over the past year I have had the great privilege of visiting 

PEPFAR services in Ethiopia, Tanzania, Mozambique, Nigeria and 

other countries. I have been inspired by the proof that there is a 

critical impact of the leadership and support of this committee of 

the wonderful work of our staff and our partners on the ground and 

of the effectiveness of the PEPFAR model as a true whole-of-government approach. 

The CDC deeply appreciates the leadership provided by OGAC 

and the important work of NIH, as well as USAID and other implementing partners. 

CDC has a unique role and history in global health. It is essentially in CDC’s DNA, going back to the 1960s and 1970s when, 

with WHO, CDC led the global smallpox eradication program. 

Among other initiatives today we detect and stop outbreaks, support epidemiologic and laboratory systems, help prevent and control malaria, support progress in the control of measles and the 

eradication of polio. 

We also fundamentally improved the capacity of partner governments to plan, implement and monitor their own programs. We 

have a unique role supporting international organizations, providing consultations, training and embedded staff. 

Today more than 2.5 million people are alive, productive and 

healthy who would otherwise have been dead or dying without 

PEPFAR. Last year 100,000 babies who would otherwise have been 

infected were born HIV free because of PEPFAR. 

The first slide shows the dramatic expansion in the proportion of 

met need for treatment in countries, the original PEPFAR countries, in the southern cone of Africa. The second slide shows the 

dramatic scale-up in treatment in recent years. 

In short, not only are communities and systems throughout the 

world dealing with HIV better, but they are better prepared to deal 

with other health problems. PEPFAR, with OGAC’s whole-of-government leadership, is working. 

We face two key challenges going forward. First we need to scale 

up treatment sustainably and cost-effectively to reach even more 

people; and second, we need to take prevention to the next level. 

When Congress had the wisdom to authorize PEPFAR and 

OGAC’s whole-of-government model, CDC was well poised to contribute because of our work globally and in this country, and their 

involvement in HIV since the first days of the epidemic. We were 

already on the ground in sub-Saharan Africa, monitoring and directing efforts to understand the nature of the epidemic, and developing and disseminating the latest science, an effective tool to control HIV. 

20

CDC and HHS is the counterpart of ministries of health, and we 

work in a peer-to-peer relationship. To implement programs effectively and sustainably, it is essential that they be inextricably 

linked with rigorous evaluation, capacity development, systematic 

laboratory and capacity tracking, and practical research. We have 

unique expertise evaluating whether investments are working, and 

doing cutting-edge research to drive improved service delivery, and 

to make more effective use of scarce resources. 

The committee has recognized that sustainable systems and 

country ownership are essential components in PEPFAR, and that 

is our commitment at CDC as well. To further scale up effectively, 

PEPFAR is transitioning to more local, sustainable and cost-effective programs. Already nearly half of CDC’s funding is implemented thorough cooperative agreements with health ministries or 

other local in-country partners, including, very importantly, faithbased organizations resident in their country, which are very important service delivery partners for us. 

Treatment costs continue to decrease as we decentralize care. 

And the next slide shows that steady decrease in unit costs as we 

transition management to local partners, streamline monitoring, 

realize cost savings through generics, and ensure treatment at the 

most high-prevalent sites for pregnant women and TB/HIV coinfected people. 

Prevention is critical. We can drive incidence down with a comprehensive package of interventions as shown on the next slide, including a series of proven and some potential but high—potentially 

high-impact interventions. Prevention of maternal-to-child transmission, HIV screening link to care and treatment, safe blood, male 

circumcisions, condoms and other proven interventions can make a 

big difference not only individually, but, as the next slide shows, 

in combination. We anticipate that there can be synergistic decreases in incidence. 

As we think of multicomponent prevention, we make the analogy 

to multidrug treatment for HIV. The breakthrough in HIV treatment came when we were able to use multiple drugs to stop replication of the virus in multiple pathways. In the same way we 

hope to have multiple ways of stopping transmission in a community to drive incidence down. 

PEPFAR is a critical platform to build the Global Health Initiative, and the whole-of-government process overseen by Ambassador 

Goosby is a model of effective collaboration. This gains efficiencies 

by using existing infrastructure of various agencies and funding 

programs based on comparative advantage. 

PEPFAR embodies the principles of GHI to achieve specific 

health outcomes, strengthen systems for sustainable improvements, 

maximize impact of all dollars, encourage country ownership, improve monitoring and evaluation, and accelerate research and innovation. 

In conclusion, PEPFAR is a tremendous success. The confidence 

this committee has had in us all is paying off in lives saved, infections prevented and systems strengthening. The interagency, 

OGAC-led model that Congress has been so supportive of is working. We are proud of the important role CDC is having in this success and will amplify PEPFAR’s success as we move forward with 

21

GHI by implementing programs which reach more people and 

stretch our dollars even further. 

We are optimistic about the future, about the ability to reach 

more people, drive down incidence, reduce costs, and build sustainable capacity. 

Thanks you very much for the opportunity to be here today, and 

I look forward to answering your questions. 

Chairman BERMAN. Thank you. 

[The prepared statement of Dr. Frieden follows:]


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Chairman BERMAN. Dr. Fauci. 

STATEMENT OF ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES 

(NIAID), NATIONAL INSTITUTES OF HEALTH 

Dr. FAUCI. Mr. Chairman, thank you for calling this hearing. Mr. 

Smith, thank you, and members of the committee. It is really a 

great pleasure for me to be able to testify before you today together 

with my close friends and colleagues Dr. Frieden and Dr. Goosby. 

What I would like to present to you over the next few minutes 

is the role of the NIH basic and clinical research endeavor in partnership to help the PEPFAR program implement its fundamental 

mission. 

As shown in this first slide, the advances in HIV research over 

the last 29 years have been really nothing short of breathtaking 

from the very beginning of the determination of the etiology, to the 

pathogenesis, rapid diagnosis, prevention modalities, treatment, 

and now the promising advances made in the arena of an AIDS 

vaccine. 

On the next slide you see the four areas that I would like to address very briefly with regard to the importance of these findings 

to the mission of PEPFAR—importantly treatments, obviously prevention, but also a word or two on capacity building and implementation science. 

On the third slide is a list of the 30 FDA-approved antiretroviral 

drugs that have been successfully used in combination to literally 

transform the lives of HIV-infected individuals. From the very beginning, in the mid-1980s, after we identified the etiologic agents, 

we began the basic and clinical research to develop these drugs, to 

prove their effectiveness in clinical trials, and to ultimately determine the optimal way to use them. This has been a great success. 

On the next slide you see some interesting figures. I began taking care of HIV-infected individuals in the summer of 1981, within 

2 months after the first cases were identified by the CDC. I have 

been doing that ever since, up to the present time. When a person 

would walk into my clinic in the summer of 1981, usually with advanced disease, the person had a life expectancy of approximately 

26 weeks. If a 20-year-old comes into my clinic tomorrow with 

newly acquired HIV infection, and I start him on this drug, I can 

confidently tell him that if he adheres to the regimen, we mathematically predict that that person will live an additional 50 years 

until they are at least 70 years old. 

PEPFAR is now beginning to translate those findings to the developing world, the countries in which they have a major impact. 

We are not exactly at those life-expectancy numbers yet, but were 

it not for PEPFAR, we would still be in the situation that I was 

in in the summer of 1981 with essentially nothing to do for these 

patients. 

If you go to the next slide, these are the proven prevention modalities for HIV. Many of these have been proven by the work of 

the NIH and the work of the CDC and other agencies. I want to 

point out three of them that have particular applicability to 

PEPFAR. 

38

The first is the prevention of mother-to-child transmission, the 

use of antiretroviral drugs to block the transmission from mother 

to child, something that is being implemented with great lifesaving 

effect by PEPFAR. Another is adult male circumcision, which NIHfunded studies proved beyond a doubt is an important way to prevent the acquisition of HIV infection. And the other is proving that 

the proper use of condoms can block the transmission of HIV. The 

issue is that we need to implement these, because only 20 percent 

of people who benefit from these preventive modalities actually 

have access to them. What PEPFAR is doing is bridging that gap. 

If could I have the next slide. You mention treatment as prevention. This is really, in my opinion as an AIDS researcher and public 

health official, an important wave of the future. Some examples of 

success already are shown on this slide. 

A very exciting study that took place in southern Africa, called 

the CAPRISA study, used 1 percent tenofovir, an antiviral, in a gel, 

to block the transmission of HIV to women who used this 

microbicide. We need to improve on this, and we will. And this is 

something that PEPFAR is very interested in implementing. 

It was shown in a study in Africa that discordant couples, one 

of whom was infected and the other one was not, if you treated the 

infected person, you had a 92 percent decrease in the transmission 

to the uninfected partner. 

And then you mentioned the issue of test and treat, which Dr. 

Frieden was mentioning. If you could penetrate the community and 

get as many people as possible on therapy, it looks now from mathematical models and as evidenced in places like Vancouver and San 

Francisco that you could actually, by decreasing the community 

viral load, prevent HIV transmission to a certain degree. 

And then finally there is the development of a vaccine. We are 

not there yet, but the results over the past few years have been 

very encouraging. 

I want to close by mentioning two additional issues. One is capacity-building, and that is to develop in-country leadership and 

strengthen the clinical and research capacity. The President mentioned this in his recent speech to the U.N., and Ambassador 

Goosby has stressed this from the very beginning. We want these 

countries and their people to be able to have the capacity to continue to do these things on their own. An example of this is the 

Medical Education Partnership Initiative with HRSA, which builds 

clinical-care capacity in sub-Saharan Africa. 

In addition, on this last slide is implementation science. What we 

mean by that is how can we best translate the research findings 

that now work in the developed world to the in-the-trenches, onthe-ground situation that Dr. Goosby and his colleagues have to 

deal with in places like sub-Saharan Africa and the Caribbean, and 

we are in strong partnership with PEPFAR in this regard. 

On the final slide I want to emphasize the common goal that all 

of us have. The NIH, the CDC, HHS, PEPFAR, USAID, all of us 

have the common goal of controlling and ultimately ending the HIV 

pandemic. PEPFAR is completely integral and essential to the accomplishment of that goal. So I strongly urge you to continue your 

strong support for the truly lifesaving program that is PEPFAR. 

Thank you. 

39

[The prepared statement of Dr. Fauci follows:]


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Chairman BERMAN. Thank you, and thank all of you. And I now 

yield myself 5 minutes to begin the questioning. 

Now, Ambassador Goosby, you touched on it, but develop this a 

little more fully. We are trying to move from emergency to sustainability. The issue of financing, of course, is quite critical. The majority of countries receiving either PEPFAR or Global Fund resources don’t have the budget to take on the full funding of these 

programs, yet these programs have to be integrated within their 

national health care system. 

Could you sort of spell out PEPFAR’s strategy to integrate AIDS 

programs into their systems and without overwhelming their budgets? 

Ambassador GOOSBY. Well, thank you, Mr. Chairman. 

You are correct to highlight that as a critical need in all of our 

program, thinking both in the past and in the future. Our ability 

to move from an emergency response to a sustained response is integrally related, and our ability to make sure that the programs 

that we have put up and established in the emergency phase do not 

lose their impact or their ability to expand to the changing needs 

of the population that use them. 

Our feeling is that country ownership is critical. By country ownership we are focused really on both the government as the public 

sector component, but also just as importantly on the community 

and the civil society around it. All three are required for the appropriate establishment of a continuum of care and services, a continuum of prevention interventions that impact the community in 

the region and areas that they are most vulnerable. So understanding the epidemic in the context of each country’s epidemic is 

the critical piece. 

Our commitment to working with countries to continue to support programming includes both a financial commitment as well as 

the realization that capacity expansion within the ministries of 

health, the ministries’ ability to play a technical assistance role for 

provincial ministries of health, are all part of the vision that we 

carry and try to align in each of the countries that we are in. 

Chairman BERMAN. Thank you. 

Dr. Frieden, you made reference in your testimony, you talked 

about your trips, and in your prepared testimony you made reference to CDC’s relationship with the African Center for Integrated 

Laboratory Training. 

Who has been trained? And does the laboratory training prepare 

technical personnel to work with diseases other than AIDS, TB and 

malaria? 

Dr. FRIEDEN. Thank you very much for the question, Mr. Chairman. The African Center trains people not just from the country 

where it is resident, but throughout the region. We have been able 

to promote laboratory network strengthening, including the beginnings of an accreditation system, so that when you get a result 

back from a laboratory, you can be confident in its accuracy. We 

have trained not only the laboratorians, but the people who supervise and manage the laboratory systems to establish sustainable 

laboratory services not just in HIV, but also more broadly to 

strengthen the health systems, whether that is TB testing or basic 

laboratory testing. 

58

I have been quite impressed by the systems that I have seen out 

there. They are very reliable. They include very complex testing, 

including CD4 counts and early infant diagnosis using the latest 

technologies, but also applied effectively within PEPFAR and to 

strengthen the system. 

So we see laboratory strengthening as one of the core pillars of 

strengthening a health system, and we have been delighted to be 

able to that with support from PEPFAR. 

Chairman BERMAN. The question—if I had time to ask and hear 

the answer to—I would be asking now to Dr. Fauci, is your remarkable testimony about some of the advances and connections between treatment and prevention. Unless you can say sort of in 

three words, but the question would be to what extent should that 

alter the way Congress approaches the funding of PEPFAR, or do 

you have the discretion within the program to make the adjustments that these conclusions might cause you to make without any 

particular changes in the way we are approaching the appropriations process? That is the question. We don’t have time for the answer. 

Mr. SMITH. I ask unanimous consent the gentleman have 2 additional minutes. 

Chairman BERMAN. Could we make it at least 1 additional 

minute with unanimous consent, because I think it is——

Dr. FAUCI. Well, to answer it in as broad an applicable way as 

possible is this just underscores in my mind how important what 

PEPFAR doing is. I mean, people often say we put a lot of money 

in something; is it really worth it? Well, the fact is that if you are 

trying to prevent infection and treat people who are infected, you 

actually get two for the price of one, because what we are starting 

to see is the support for treatment isn’t at odds or in competition 

with prevention, it is actually part of prevention. So when you hear 

people from PEPFAR say that, when you hear Tom Frieden and his 

colleagues from the CDC say that, it really is true. 

I mean, all the data that is starting to accumulate now means 

that, in fact, you can, by treating people appropriately, ultimately 

prevent infection. So we have got to put aside the tension between 

treatment and prevention. They synergize with each other. 

Chairman BERMAN. Thank you. 

And now I am pleased to yield 5 minutes to the gentleman from 

New Jersey Mr. Smith. 

Mr. SMITH. Thank you, Mr. Chairman. 

First of all, let me thank you for the most recent addition of enrollees for Uganda. I had been very critical—I am not the only 

one—that there was a straight-lining, and some additional 36,000 

people in Uganda will now get ARVs courtesy of the United States 

Government. So thank you for doing that, especially in light of the 

double duty that treatment is prevention, and I think that is very, 

very encouraging. 

Dr. Frieden, if you could maybe touch on briefly the issue of safe 

blood. I actually held a hearing several years ago when I chaired 

the Africa Subcommittee, and one of the issues we learned from 

WHO is maternal mortality can be reduced by 44 percent, according to the witness from WHO, if safe blood were available. I know 

59

you have 14 initiatives going. In your testimony you speak to it. 

Maybe you might want to touch on that. 

And secondly, according to the WHO, and I said this in my opening statement, an overwhelming amount of health care is provided 

by faith-based entities—under the auspices of faith-based communities in Africa. Forty percent of that is delivered by the Catholic 

community, and worldwide the Catholic community provides 25 

percent of all care and prevention for HIV/AIDS patients. 

I would argue that failure to aggressively include faith-based organizations in the Global Health Initiative will seriously undermine the efficacy and sustainability of our struggle to mitigate and 

hopefully end this pandemic that has so ravaged Africa and other 

parts of the world. 

I understand that the country ownership issue is central to the 

Global Health Initiative. Yet given the poor track record of the 

Global Fund, to which U.S. taxpayers donate over $5 billion and 

counting, in its national ownership scheme known as the Country 

Coordinating Mechanisms, could you tell us what the administration is doing to ensure that faith-based organizations are not discriminated against in the allocation of grants at the country level? 

How does that figure into our partnership framework agreements? 

Are we saying this is something we think is important? Why create 

a new infrastructure when there is a preexisting one where rollouts 

can occur? And how do you plan to ensure that PEPFAR’s conscience clause, which I offered to the original law—and it was actually strengthened when we went through the reauthorization. And 

Chairman Berman, the Democrats and Republicans were of one accord in strengthening that conscience clause—so that when it gets 

to that country level, the conscience clause is not shredded, and 

these faith-based organizations are not shown the door, and they 

are part of delivery of services? 

Dr. FRIEDEN. Thank you very much. I will start, and then perhaps Ambassador Goosby will address it as well. 

The safe blood program really is a success story. It is now scaled 

up to all 60 countries with technical assistance, and it has been 

done in a way that builds local capacity. It has not been an external system imposed, but a system of helping countries establish, 

monitor and maintain a safe blood system, and that is critically important and a real win in HIV prevention and in confidence in the 

health care system. 

So I think it is a great example. It is an example of prevention. 

It is working, and, very importantly, it is working by building systems. I met with the staff who had helped to grow that. They were 

essential in improving that quality. 

And as we transition through the Global Health Initiative, we 

will be looking also at the appropriate use of blood and increasing 

to make sure that it is not being used when it is unnecessary, and 

is being used adequately, such as in the reduction of infant mortality where hemorrhage is a leading cause of death. And addressing emergency hemorrhage is something that we hope to be able 

to do in the Global Health Initiative as we transition from prevention of mother-to-child transmission to a broader sense of protecting mothers’ lives. 

60

In terms of faith-based organizations, I agree completely. In 

many countries in which we work, there are superb service delivery 

platforms. They provide services where there are no other service 

providers. They provide them with very high quality and at very 

low cost, and we see them as essential partners, and we continue 

to work with them. In fact, as I mention in my oral statement, as 

we transition to local partners increasingly, and we are already—

45 percent of our grants are local partners rather than U.S.-

based—but as we continue and expand that transition, faith-based 

organizations have a very essential role to play. 

Mr. SMITH. Real quick. 

Chairman BERMAN. We can give you unanimous consent for 1 additional minute for the full answer to this. 

Mr. SMITH. I mentioned the Global Fund because I have met 

with the Global Fund many times and their leadership about the 

exclusion of faith-based organizations, especially at the country coordinating mechanism level. 

In many of these countries, as we know, for years the churches 

collectively have been the bulwark in protecting human rights, and 

very often they are seen as the thorn in the side of governments, 

particularly as they matriculate from dictatorship to a democracy. 

So there is a reason to keep them at bay and look for other partners. And again, who hurts? It would be the potential patients. 

Ambassador GOOSBY. Well, let me just echo Dr. Frieden’s statements around the faith-based organizations. They have historically 

played, as you have really eloquently outlined, a critical role in the 

delivery of health care in sub-Saharan Africa in particular. As you 

move from urban to rural, their importance increases, and in many 

countries where PEPFAR is working, the faith-based organizations 

really comprise the district hospital-level capability in many of the 

rural areas that we are in. 

That role is not going to change. Indeed, in many countries the 

faith-based organizations are part of the public health system. 

When a graph is charted of their referral, tertiary, secondary and 

district-level hospitals, the faith-based organization is often playing 

that role solely, as I said. They also have a series of clinics that 

reach out from that hospital base that again extend their reach and 

have been extensively engaged with in all of our programs in 

PEPFAR with completing continuums of care in services in both 

treatment and prevention fronts. 

So we are committed to continuing that and would look, if you 

had examples of concern or issues where it has come to your attention that someone has been excluded, we would be very interested 

in engaging with that directly. 

I would finally answer your Global Fund question to say that the 

CCM process, the country coordinating committees, are locally determined as to who sits on those seats. We do give a significant 

amount of resources to it. We see the Global Fund and PEPFAR 

as joined at the hip; our success is interdependent. Our planning 

together and defining unmet need and allocating resources is now 

getting much more sophisticated so the duplication overlap, the 

ability to take advantage of common procurement distribution systems, administrative oversight management, et cetera, it is all 

moving forward. 

61

We believe——

Chairman BERMAN. Ambassador, the time has more than expired. So perhaps there is a way to get back to that. 

The gentlelady from California Ms. Lee is recognized. 

Ms. LEE. Thank you very much. And, yes, Mr. Chairman, we will 

get back to that. 

And let me just say I am glad you mentioned that Dr. Goosby 

has a California connection, but I am very proud to say he is my 

constituent——

Ambassador GOOSBY. Absolutely. 

Ms. LEE [continuing]. And has done a very fine job in this position also, as he has in previous positions. 

With regard to the Global Fund, following the International 

AIDS Conference, of course, I sent a letter to the President along 

with 100 Members of Congress asking for $6 billion over 3 years 

to fight—well, committed to the Global Fund. Together with 

PEPFAR our contributions have been responsible for treatment of 

5 million people worldwide. So next week in New York, of course, 

the Global Fund is holding its replenishment hearing, and I wanted to find out where the administration stands on this request for 

a $6 billion pledge. Can we reach that target? If so, great; if not, 

why not? 

I think it is very important, because we want this announcement 

to be clear so that we can begin to leverage contributions from 

other donors who are still considering their pledge. So that is one 

question, Dr. Goosby. 

And then my second question any member of the panel could answer as it relates to the joint United Nations program on 

HIV/AIDS. I have been asked to serve as a Commissioner on the 

Global Commission on HIV and the Law. This new international 

Commission, the objective is to develop actionable, evidence-informed, and human-rights-based recommendations supporting national legal environments that enable effective HIV responses and 

realize the human rights of those living and affected by HIV. The 

Commission will hold three meetings over the course of 18 months. 

The first meeting, of course, is next week in Brazil. 

So I wanted to find out if you are aware of the Commission and 

its goal? Is the United States providing any direct support, whether 

technical or material, of the Commission? And can we count on 

your input, because I would like to talk to you about our input in 

terms of helping to overcome some of these legal barriers to providing access to services and to encouraging the research that is 

really necessary to fight this disease. 

Ambassador GOOSBY. Well, thank you, Congresswoman Lee, and 

you are my Congresswoman. Thank you. 

I think that the relationship between PEPFAR and the Global 

Fund has evolved. Our presence as a Board member on the Global 

Fund and our engagement with both the Executive Director and 

the Secretariat has given us an increasing opportunity to again lay 

this trackwork to merge our resources in a way that is highly efficient and increases both of our programs’ impact at the country 

level. We are excited about that merging. We believe this will bring 

many more people into our care and treatment and prevention 

services and will save many more lives. 

62

Our ability to have a meaningful relationship with the Global 

Fund has been one of iterative dialogue around strengthening 

mechanisms for both the Secretariat as well as the CCM process. 

As the PEPFAR programs have staff in country, we are intimately aware in 80 countries in which we overlap with Global 

Fund of a lot of the implementation issues that come to bear, such 

as we saw in Uganda where our programs are connected to theirs. 

If Global Fund programs are performing well, we move together. If 

either of us fall in that ability to move patients through, to identify 

clients, to address and deliver services, there is a displacement of 

patients into the other’s programs. And we have seen this in many 

of the other countries we are in. 

In order to minimize that, to anticipate it and to prevent it, we 

are really moving aggressively over the next few months to a 

shared planning and implementation vision. 

The Global Fund is part of our success and will continue to be 

an integral piece of how we are able to increase our ability to impact. 

Ms. LEE. Bottom line is how about our pledge for 3 years? 

Ambassador GOOSBY. We have been aggressively involved in a 

dialogue over the last few weeks. That dialogue has continued 

through this week. We will come to replenishment next week with 

a proposal that I believe is strongly supported within the administration. It has required a new vision and new commitments being 

made on our part——

Ms. LEE. Dr. Goosby, do you think that the 101 members that 

signed that letter will be strongly supportive of the recommendation? 

Ambassador GOOSBY. I think that we always appreciate the 

input from our congressional leaders and the insight and wisdom 

that they bestowed on us through that letter was greatly appreciated, and all of those issues were taken into account in the discussion. 

Ms. LEE. You sound like a lawyer. 

Thank you very much. 

Chairman BERMAN. They appreciate the 101. We don’t know 

whether the 101 appreciate them. 

Ms. LEE. Can I get a response? 

Chairman BERMAN. By unanimous consent, the gentlelady has 

an additional minute. 

Ambassador GOOSBY. We are very supportive of that effort. We 

are thrilled that you have committed to giving your time and 

thoughts to this. The connection to health and human rights is 

basic, fundamental, needs to be amplified and we are supportive 

and will be supportive of the committee. 

Dr. FRIEDEN. Similarly, we would be delighted to be supportive 

in any way with our colleagues. I will emphasize one area in particular, which is gender-based violence, where CDC studies in multiple countries in Africa have shown this, particularly 

intergenerational gender-based violence to be far too common and 

a driving force behind the epidemic. So this is one area which is 

not only a terrible human rights violation but also a driver of the 

epidemic. 

63

Chairman BERMAN. The gentleman from Arizona, Mr. Flake, is 

recognized for 5 minutes. 

Mr. FLAKE. Ambassador Goosby, when the last reauthorization 

came in in 2008, there were several requirements put into law in 

terms of reporting having to do with best practices and efficiencies. 

It is my understanding that those reports have not been issued. If 

not, why not? And how can we be expected to reauthorize or appropriate more money without some of the requirements having been 

met? 

Ambassador GOOSBY. Well, thank you, Congressman Flake. Perhaps the central emphasis since I have started this position has 

been to look at, especially in this economic decline, all areas that 

we can engage in to become more efficient, to take advantage of 

synergies and collapsing of resources so they are truly additive 

within the program as well as between the programs. 

We have created a process that has canvassed every country that 

we are in. Thirty at a high level, but all 80 countries. And we have 

compiled a strategy that is focused specifically on identifying and 

integrating these strategies into an identification of efficiencies 

that become programmatic and entered into our budgetary relationships. 

We have completed a document that I had thought had come to 

you. It has been submitted to the committee, but you obviously 

haven’t seen it. We will work with your staff to make sure that you 

get that forthwith. 

Mr. FLAKE. This will comply, or be responsive to the requirements in the 2008 reauthorization? 

Ambassador GOOSBY. Yes, sir. 

Mr. FLAKE. I will yield the rest of my time to Congressman 

Smith. 

Mr. SMITH. I thank my good friend for yielding. 

If I could just, Dr. Goosby, get an answer. In the partnership 

framework, is the conscience clause included there, because obviously, while we are encouraging local control, it is never absolute. 

Obviously, we have parameters. Is it in there? 

Secondly, I was at a roundtable last week at the U.N. Development Goals Summit at the United Nation run by the Rockefeller 

Foundation and GAIN, and seven first ladies, led by Lady Odinga, 

emphasized the first 1,000 days of life from the moment of conception is a wonderful event, which obviously that will predict what 

happens in the next, 25,000 hopefully, days of life, if someone can 

live into the seventies. 

But it was from the moment of conception, it was all about good 

nutrition and it was an affirmation of life before birth, that an unborn child is sacred and precious, and birth is just an event that 

happens to all of us. It’s not just the beginning of life. 

I would note the next day the Secretary of State was at a similar 

unveiling with the foreign minister of Ireland during which she 

wouldn’t say the words ‘‘moment of conception.’’ Okay. That is unfortunate. But it is still the same idea. Those first 1,000 days are 

absolutely crucial. And with PEPFAR, Don Payne was very emphatic on this, as was I, as chairman and ranking member of the 

Africa Subcommittee, that nutrition is crucial to PEPFAR. 

64

It is contradictory to me that on the one hand, Global Fund is 

talking about reproductive health including the killing of the unborn child by way of abortion, and we are also talking about nutrition and providing protection and all the possible enforcement 

backstopping for that baby in the first 1,000 days. 

Finally, behavior modification, and I assume that is A and B of 

the ABC model. Doctor Eliodo—head of the Ugandan member of 

parliament—has said very clearly that the B is so important—A is 

important—but the B is so important. When there are multiple 

concurrent partners, the epidemic continues to spread notwithstanding perhaps ARVs. So what about the emphasis on the B? 

But if you could get into the conscience clause first. 

Ambassador GOOSBY. Yes, Congressman. 

The partnership framework is an attempt to engage in a new 

dialogue with country to establish a commitment to relative contributions from our partner country as well as the United States 

Government over a 5-year period. It is under the PEPFAR legislation, and the conscience clause does apply to that dialogue. In 

terms of the Global Fund and the chart that you mentioned——

Mr. SMITH. Is it binding or is it just part of the dialogue? 

Ambassador GOOSBY. We legislatively are bound by the conscience clause legally so we cannot agree to something that is outside of the parameter. 

Chairman BERMAN. The gentleman from North Carolina, Mr. 

Miller, is recognized for 5 minutes. 

Mr. MILLER. Thank you, Mr. Chairman. 

I think all of you have spoken of pediatric HIV/AIDS. And I have 

been stunned when I traveled in Uganda on a congressional delegation 3 years ago at how pervasive transmission from mother to 

child is very rarely in the United States and very common in the 

developing world. It certainly makes the goal of eliminating all pediatric HIV by 2015 look to be an enormous task. 

And the precautions that are routine that are universal in the 

United States are almost unheard of in other parts of the world, 

and as a result, thousands of children every year begin life with 

HIV, either born with it or through contracting it through breast 

feeding. The routine precautions beginning with the testing of pregnant women with HIV is almost unheard of almost all the way 

through. 

What are the barriers? Is it all the amount of resources? Are 

there other barriers? What stands between us and having the 

transmission of HIV to children from their mothers is as rare in 

other parts of the world as it is in the United States? Dr. Frieden? 

Dr. FRIEDEN. Thank you very much, Congressman Miller. 

It is a great question, and I think this is an area where we are 

poised—we have had a lot of progress in the last couple of years 

and we are poised to have even more progress. We have countries 

that now have moved to a universal screening for HIV and pregnancy. So we are seeing a substantial scale-up of effective prevention. 

There are a series of barriers. First, in some countries the proportion of women who give birth in an institution or are attended 

is in the single digits. So when you have a service delivery gap that 

is that large, it shows you some of the limitations of a program 

65

that is within the envelope of HIV only. That is one of the reasons 

why we think the global initiative will actually greatly strengthen 

not only health systems but also HIV prevention and prevention in 

terms of the mother-to-child transmission. But there has been tremendous progress in recent years, testing more women, getting 

more women on treatment, getting the children appropriately cared 

for. 

The second key issue is the effectiveness of treatments. Some of 

the regiments require the women to take medications and take additional medications during delivery. But if that delivery is not attended because, for example, of co-payment charges at institutions, 

then the investment that we have had to protect that child is not 

fulfilled really and the child becomes infected. 

So there are ways that we need to change the way women are 

cared for and focus on women getting care before, during and after 

pregnancy. There is also the challenge of breast feeding and reducing the risk during breast feeding. And there are some real challenges there in terms of the women’s experience. The data from 

this comes from trials led by both CDC and NIH, and I think it 

is a success area, but one where I think we need more progress. 

Dr. FAUCI. I agree completely with Dr. Frieden’s assessment. I 

think it also underscores what we were saying before about the 

penetration into the community of getting people tested and treated. We need to think not only that we have to prevent transmission 

to the baby, but also that we have to treat the mother as an individual, and then you will do two things: You will prevent transmission to the child, and you will also prevent transmission 

through breast feeding. 

As Dr. Frieden said, really the opportunity is extraordinary. The 

more people we test, the more people we treat. Among those will 

be women who either will be pregnant or are pregnant, and then 

you have the secondary benefit of preventing the transmission to 

the child. 

Mr. MILLER. Similarly there have been—the other parts of the 

world lag well behind in early diagnosis of children with HIV. 

What are the barriers to earlier diagnosis and therefore earlier 

treatment? 

Dr. FRIEDEN. We have been delighted to be able to work with a 

series of African countries to build up a capacity for early infant 

diagnosis, and I was delighted to see, for example, in Mozambique, 

the reference laboratory using the text messaging technologies secure through return results very rapidly so that children, infants, 

could get on treatment. And that kind of innovation is what we 

hope to see more of, getting cutting-edge laboratory services 

through dried blood spot and then getting the results back to the 

treating physician right away so that they can start treatment rapidly right away if needed. That early infant diagnosis is also very 

important. Has a quality assurance mechanism. We know we are 

treating women, testing women, but are we preventing transmission? And that is a critical mission for us. 

Ambassador GOOSBY. If I could just add an anecdote to that. The 

remarkable moment at birth and having the child there and having 

to wait for antibody production over an 18-month to 2-year period 

has been preempted with the ability of early infant diagnosis. And 

66

PEPFAR is committed to expanding that capability in all of our 

programs to allow individual children to get on both cotrimoxazole 

as well as antiretrovirals at birth. 

Chairman BERMAN. The gentlelady from California, Ms. Woolsey, 

is recognized for minutes. 

Ms. WOOLSEY. Thank you, Mr. Chairman, and thank you to the 

panel. I want to take this just one step further and then I have another question to ask also. 

So when women are unable to obtain family planning information and the appropriate prevention methods, NuvaRing, shots, 

condoms, because of the complications that come along with the 

conscience clause, or maybe that doesn’t happen, tell me if I am 

wrong. But when we make it difficult for women to prevent pregnancy in the first place, and quite often that would prevent AIDS 

and HIV with the appropriate prevention products, what impact 

does that have on HIV/AIDS and the numbers before we start 

treating it? 

Ambassador GOOSBY. Well, I can take an attempt at that. It is 

a difficult question. It is a good question. We have been very aggressive at talking with our partners who we are engaged with at 

the country level to understand their concerns around making 

available a referral mechanism to family planning reproductive 

health services. That usually is doable. And it is a commitment on 

part of the institution itself who has difficulty moving forward with 

those services on their own site, but allowing the patient in front 

of them with that immediate need to be addressed and referred in 

a seamless way is our goal. 

We have been able to engage in that in most every instance that 

it has come up, and will continue to honor both the conscience 

clause in that effort, but also being clear that our real responsibility to the patient in front of us is to respond to her needs. Thank 

you. 

Ms. WOOLSEY. Speaking about her needs, without taking anything away from HIV/AIDS support and investment, both from the 

United States and internationally, what would it take for this same 

group of partners to invest in maternal mortality and child mortality at the same time? I mean, my goal is not to take anything 

away from the successful HIV programs, but to build on that and 

to go into the next level of maternal health. 

Ambassador GOOSBY. I will take the first attempt at that. We are 

thinking alike. President Obama’s Global Health Initiative is an attempt to do just that, to take the successful programming that we 

already have in place—in this instance HIV/AIDS—to use that robust medical platform to build onto, to add to, services that allow 

the same patient with HIV in front of us who has needs in maternal and child health, family planning, neglected tropical diseases, 

immunizations for the children, other family members, as well as 

a package of essential services for hypertension, diabetes, whatever, defined by each country, this is an attempt to do just that. 

Build on the platform that is already in place, to expand the services that are needed by the population that we have already captured. 

Ms. WOOLSEY. Dr. Frieden, I am not suggesting that we take the 

same pot of money, and then expand the services and I am also 

67

suggesting that there are women, and young women, that don’t 

have HIV. So how do we get to them and set up—I don’t want it 

to only be women who are already infected. 

Dr. FRIEDEN. Through the PEPFAR support we have been able 

to strengthen health systems; we have been able to improve the 

quality of delivery; we have been able to increase access to emergency obstetrical care, and this is critically important for HIV prevention, and also to support women’s health and child health. And 

I think, you can see an evolution from the PEPFAR reauthorization, which enables us to strengthen systems more comprehensively, so that we would not only have a more sustainable way of 

achieving the outcomes of PEPFAR, but also improve other health 

conditions through the Global Health Initiative, where we are saying we are going to take all of our investments we know that we 

are in a scarce resource environment, we know that every dollar is 

precious, and we are going to stretch each of them as far as we can 

by having the services that are available as efficiently and as close 

to the client as possible. 

Ms. WOOLSEY. Dr. Fauci, before you answer, try to add into if 

this were a perfect world, and we really cared about children and 

their mothers, what would it take from the United States? 

Chairman BERMAN. By unanimous consent, the gentlelady has 1 

minute—not until we have a perfect world. 

Dr. FAUCI. I can do it in less than one. 

In fact, Congresswoman, that is exactly what the fundamental 

philosophy and strategy of the President’s Global Health Initiative 

is—exactly what you are saying. PEPFAR is a major component of 

that, but within the Global Health Initiative is exactly what you 

are referring to, not only have both an independent as well as 

interdigitating approach toward women’s health and child mortality but also have it something that has its own force and its own 

life apart from PEPFAR. 

But they are so closely joined, that you can almost not separate 

them. 

Ms. WOOLSEY. Thank you very much, Mr. Chairman. 

Chairman BERMAN. Time of the gentlelady has expired. The gentleman from Minnesota, Mr. Ellison, is recognized for 5 minutes. 

Mr. ELLISON. Mr. Chair, thank you for this really important 

hearing and thank you to our witnesses. 

Could you talk about the issue about the scarcity that you mentioned a moment ago? I am curious to know how are our country 

partners addressing and augmenting the battle to overcome AIDS 

and HIV? Are we seeing legislatures from the countries that we are 

partnering with appropriating money to the degree that can handle 

some of the outyear cost associated with the ARTs and so? Could 

you address this? 

Ambassador GOOSBY. Thank you, Congressman. It is an excellent 

question. 

Our whole approach with the partnership framework is to engage 

in a different dialogue with each country around the human resources, the financial resources, the administrative resources that 

are needed to continue a specific outline of programs that the partner government is contributing to and the United States Government is contributing to. 

68

Over a 5-year period, we define it explicitly and include in that 

an expectation and time line around commitments. 

The dialogue is with country leadership. That leadership has 

largely been central with the Ministry of Health, but the Minister 

of Finance comes into it eventually always. The President frequently blesses it and/or signs it. We have had multiple, in every 

country that I go to, I meet with leadership, including legislative 

appropriators, and have had difficult discussions around relative 

contributions on a financial level to this effort. 

Nigeria is a good example of this. Deputy Secretary Lew and myself went to Nigeria and in addition to looking at programs, we met 

with the President, with the Appropriations Committee, with legislative leadership on multiple party levels. We have also met at the 

provincial level with leadership as well. 

All of it was a discussion around what can we expect in a country 

with an emerging economy, such as Nigeria, to assume in the monetary support of these services. Again, remaining committed to administrative and continued support on part of the United States, 

it was the first time we got into an explicit dialogue around what 

portion of that monetary allotment can you realistically begin to assume for yourself. 

Nigeria came in within at the end of their 5-year period that 

they would assume 50 percent of the cost. That was a huge increase from where they are currently, and a sincere commitment 

made by both appropriators and the President. 

Mr. ELLISON. I am glad you all have that conversation because 

I think it could have some benefits to other health challenges that 

a lot of other emerging countries are facing. If you can develop a 

system to address HIV/AIDS, you can do that, perhaps, for malaria 

and other things. 

Let me ask you this much, too. How much input do partner countries have into how we are appropriating PEPFAR dollars in their 

own country? I have had a chance to spend some time in Kenya 

and learned they have more deaths from malaria than they do from 

HIV—of course, both are serious problems. But talk to me about 

how much input our partner countries have into directing how 

PEPFAR resources are allocated? 

Ambassador GOOSBY. I will very quickly say that our initial response with PEPFAR was an emergency response, and we deployed 

largely through NGO continuums of care and services with 

partnered governance and civil society. 

We, in the second phase of PEPFAR, looking at the emergency 

response, moving into now sustained responses, see the need to 

move more aggressively and to a different dialogue with partner 

countries around their relative management, ownership, oversight, 

defining unmet need, prioritizing unmet need, and being in and 

part of the allocation discussion. 

This is in most of our countries a new and expanded dialogue for 

PEPFAR. It is a dialogue that the President and the Secretary of 

State feel very strongly about, I feel very strongly about, that this 

is the conduit through which we will really achieve sustainable, durable programming. 

Mr. ELLISON. I guess my last question is the U.S. Congress is a 

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ple bring their agendas here. Unfortunately when it comes to foreign affairs, our agenda gets pressed on other people outside of our 

borders allotted. And when it comes to——

Chairman BERMAN. The gentleman has an additional minute. 

Mr. ELLISON. When it comes to programs like PEPFAR and 

PEPFAR, for example, are there certain things that Members of 

Congress here think are very important to them and maybe important to their constituents but that create complications when they 

are translated into the work that you have to do? So, for example, 

well, I’ll leave the example out for the moment. 

Ambassador GOOSBY. It is a an astute question. But an understandable dissonance is created with our congressional bodies and 

the constituencies within our Congress moving forward in a Congress. We have that same dissonance set up in our country dialogue as well because each country is different, has different norms 

and self-expectations that must be considered and acknowledged 

and incorporated into the plan as we move forward. 

That sensitivity and where we draw that line is much of what 

our dialogue becomes in the actual final partnership framework 

discussion. We are acutely sensitive to it, but also have frames and 

references that kind of define our parameters and how far we can 

go in both ways. 

So it becomes a dialogue. 

Chairman BERMAN. The time of the gentleman has expired. 

The gentleman from New Jersey, the chair of the Africa and 

Global Health Subcommittee, Mr. Payne, is recognized for 5 minutes. 

Mr. PAYNE. Thank you very much, Mr. Chairman. Let me commend you for having a full committee hearing on this very important subject. It is so good to see our panelists, Dr. Goosby and Dr. 

Frieden, and who has been a longtime friend from New Jersey, Dr. 

Fauci. We can’t think of anything that is more important right now 

as it relates to the developing world. And I think that the program 

of PEPFAR was really a program that made many of us very 

proud, even with the first authorization of the $15 billion over 3-

year period. This was a quantum leap from what we had been 

funding. 

As you know, funding for HIV/AIDS has—even here in the U.S.—

gone very slowly, and when it was first diagnosed, in the early 

1980s, there was only several hundred thousand dollars that actually was appropriated over the course of 3 or 4 years in the 1980s, 

where we simply allowed this to fester and continue. There was 

very little attention given. 

So we have continually commended President Bush when the notion of increasing the PEPFAR program—of course, we had the majority in the House, but we did need the cooperation from the 

White House and the President did agree to double it from $15 billion, and I was advocating with them. But then I thought if he was 

willing to go along with $30 billion, that that wasn’t enough. So we 

pushed the $50 billion number, and we were able to get a $48 billion reauthorization, which I think was one of the greatest marks 

of our country’s foreign assistance program in its history, and has 

done so much to save so many lives. 

70

I know they have been recognized, but I understand the 24 

women from Parliament, and several First Ladies from Ethiopia, 

and Deputy Prime Minister of Zimbabwe are here. It is great to 

have you here in the audience. I look forward to meeting with you 

later in the day. 

Let me ask, Ambassador Goosby, we do know that you need to 

have the participation and cooperation from local people to move 

this program forward, and anyone can chime in. 

But specifically, let me ask you, what is the role of local, national, and international nongovernmental organizations and civil 

society in designing and implementing the PEPFAR program? Just 

how much are they engaged on the ground and so forth? 

Ambassador GOOSBY. Congressman Payne, let me first say thank 

you for your leadership, longstanding leadership in this arena, both 

domestically and internationally. 

We have seen an emergency response in PEPFAR move to a sustained response. We are scrambling now to implement that shift 

from emergency to sustainable. It brings in country ownership. The 

country ownership aspect includes government as well as civil society. And I would include certainly the NGO community as an integral part of that civil society component. 

We feel that they have and will continue to play the critical role 

in prioritizing and defining our implementation needs with the dialogue in our partner countries. 

The final role that we seek to complete and improve the chances 

of sustainable durable program is to work in civil society, to establish a voice that is in and amongst those who use the services to 

give feedback to allocators and appropriators around the appropriateness of their allocation. When you keep that dialogue present, 

and when you create a safe space for that dialogue to occur, the 

program becomes self-correcting. When you don’t, it is ephemeral 

and fragile. So we are committed to that third component. 

Mr. PAYNE. Thank you very much. 

Let me just ask this last question before my time expires. 

The good news is that HIV-infected persons with either latent TB 

infections or active TB can be effectively treated. It would maybe 

be Dr. Frieden or Dr. Fauci who would want to answer. How is 

PEPFAR aggressively addressing the TB/HIV co-infection issue? 

Chairman BERMAN. Without objection, the gentleman has 1 additional minute. 

Mr. PAYNE. Thank you, Mr. Chairman. 

As you may recall, about 4 or 5 years ago, we found in South Africa about 53 or 54 persons who had the virus, Bishop Desmond 

Tutu wrote a letter that when the infection of the TB came 

through, 53 of the 54 people died within several weeks. So I wonder if you could respond to that in the time that I have left. 

Dr. FRIEDEN. Thank you. I will try to summarize my 10–15 years 

working in tuberculosis control globally in the next 30 seconds. 

Fundamentally, it is a question of good management and significant PEPFAR resources are going into improving the management 

of tuberculosis. Many of the countries in Africa had functioning tuberculosis-control systems, but when HIV came in and tripled the 

number of cases they were overwhelmed. 

71

The most effective way we can reduce TB is to scale-up treatment for HIV at this point because that drives down numbers, but 

often, TB comes before we treat at the current guidelines. So the 

challenge is to make sure that the patients are promptly treated 

and fully treated and we work closely with countries throughout 

Africa to improve their treatment systems and improve the ability 

to diagnose and ultimately treat the resistant forms of drug-resistant forms of tuberculosis. 

What we do hope is that by scaling up effective treatment, we 

can prevent that in the first place. 

Chairman BERMAN. The time of the gentleman has expired. 

We don’t often get the three of you here together so that we are 

going to allow Mr. Smith and then Ms. Lee to each have 1 minute 

for a last question and answer. 

Mr. SMITH. Because of time, some of the questions were unanswered. Dr. Goosby, again, the Board of the Global Fund talks 

about funding abortion. Is that the administration’s view? And secondly what priority is given to A and B, the abstinence and befaithful part of the ABC model? 

Ambassador GOOSBY. Congressman Smith, I really have to say I 

need to look at that because that will be something that we would 

want to understand better and we will definitely get back to you 

on that in terms of what the Global Fund is saying. 

In terms of what the commitment to our conscience clause and 

the abstinence and being faithful. The abstinence and being faithful, we continue to fund at high levels, and I would be very happy 

to go over it in great detail with you country by country, the abstinence and be faithful efforts. And as I said in the previous question, we had linked referral mechanisms so services that are needed that fall out of the abstinence and be faithful response can be 

addressed as well. 

Chairman BERMAN. The time of the gentleman has expired. The 

gentlelady from California, 1 minute. 

Ms. LEE. Let me just say when we were in Vienna, there was a 

lot of discussion about men having sex with men and how they are 

19 times more likely to be living with HIV other than the general 

population. So what are we doing to ensure that countries are actually attempting to provide services to this vulnerable population 

without stigmatizing or jeopardizing the privacy and safety of these 

individuals? 

Ambassador GOOSBY. It is a very good question, Congresswoman, 

in terms of in a high interest and focus for PEPFAR. 

Men who have sex with men are complicated in sub-Saharan Africa. For example, in Malawi, 67 percent of the men who have sex 

with men are married. They have families. And they perceive 

themselves in the community and present themselves in the community as heterosexual. That kind of stigma that pushes that revealing oneself to family and community down is something that 

PEPFAR has attempted to develop unique strategies that are different in each neighborhood and each region to try to create safe 

spaces so an individual can indeed access services. 

We also have a diplomatic component that engages in dialogue 

at the Presidential level and at legislative levels in country to express concern with legislative responses to behavior patterns that 

72

are unacceptable in the country but have criminal associated consequences for them. And we are engaged in multiple countries on 

that front. 

Chairman BERMAN. The time of the gentlelady has expired. I 

want to thank all of you very much for making time in your schedules to be here today, and I appreciate all you are doing in this effort and your leadership, and thank you.

We now have a second panel, people right out there in the field. 

If the two witnesses could come up. 

Paula Akugizibwe is a citizen of Rwanda, is currently based in 

Cape Town as the advocacy coordinator at the AIDS and rights alliance for South Africa. ARASA conducts training and self-advocacy 

in the southern region to improve access to TB, HIV services and 

to advance a human rights base response to health. 

Dr. Wafaa El-Sadr is professor of medicine and epidemiology at 

Columbia University, the director of the International Center for 

AIDS care and treatment programs, and the director of the Global 

Health Initiative at Columbia University’s Mailman’s School of 

Public Health. ICAP, the center she founded and currently directs, 

works in 14 countries in sub-Saharan Africa in partnership with 

governmental and nongovernmental organizations building in-country capacity for HIV prevention care and treatment. 

We are delighted to have you with us this morning. And we look 

forward to your testimony. Your entire statements will be included 

in the record. 

Ms. Akugizibwe. 

STATEMENT OF MS. PAULA AKUGIZIBWE, ADVOCACY COORDINATOR, AIDS AND RIGHTS ALLIANCE FOR SOUTHERN AFRICA (ARASA) 

Ms. AKUGIZBWE. Mr. Chairman, committee members and distinguished guests, good morning and thank you for this invitation to 

testify before one of the most historically significant committees on 

global policy on what is probably the most significant issue on global health. 

The establishment of PEPFAR in 2003 represented an unprecedented response by the United States to a global health problem 

which had far-reaching implications with development. The founder 

of the U.N. AIDS wrote that PEPFAR changed the landscape elevating AIDS issues to one of the big political themes of our time. 

In 2008, under the leadership of this committee, you enhanced 

that commitment with the visionary Lantos-Hyde Act which set 

forth a ground-breaking direction for the future of global HIV funding and helped to significantly strengthen our resolve to fight HIV 

in African countries. As the Lantos Foundation previously stated, 

to some, HIV treatment and prevention is seen as a burden on the 

U.S. taxpayer. Instead, it should be seen as an investment that has 

already paid for itself many times over in goodwill toward our 

country and hope restored in African communities. 

There is no question that PEPFAR has great erased the stigma 

in the African region and rightly so. It remains an initiative for 

which millions of people across the continent are grateful, an unquestionable investment in public perception of the U.S. enhancing 

global security. 

73

It is critical to acknowledge from the outset that the value of 

PEPFAR is not limited to dollars, cents, and public health statistics, but extends to significant political impact. 

The political world resources that were mobilized by the U.S. for 

the fight against HIV reverberates across the world at a time when 

AIDS was estimated to be decreasing the TDB of high-prevalence 

countries in Africa by an average of 1.5 percent per year. Increased 

investment in HIV gave us an opportunity to bend these economic 

and epidemic curves which has led us to where we are today—at 

a tipping point for global health, balancing precariously between 

the good news and the bad news. 

The good news, which we have heard this morning, is that we 

are not fighting a losing battle. There is ample evidence that we 

are bending the curves, that the once illusive dream of an HIV-free 

generation is eminently achievable changing the question from ‘‘can 

we?’’ to ‘‘do we want to?’’

The bad news is that without increased resources now, our 

chance to defeat HIV must slip from our grasp and the climate of 

AIDS could return. It would be tragic for this to happen in the context of some of the most encouraging leaders in the history of the 

HIV epidemic, which we have heard in the past couple of years and 

we have heard this morning as well that AIDS deaths are declining 

globally for the first time since 2007. The HIV incidents is declining especially in sub-Saharan Africa, and that treatment has 

turned out to be a most effective biomedical prevention tool. 

A U.S.-funded study as was cited earlier showed that treatment 

reduces the transmission of HIV by approximately 90 percent with 

incredible long-term cost saving potential. 

Modeling studies presented at the Vienna Conference indicated 

that universal access in South Africa, if fully funded today, would 

result in a 17 percent reduction of transmission over 3 years 

achieving cost break even in the same space of time. 

In the time of economic crisis, it is politically and financially expedient to look to short-term savings, but long-term social economic 

rationale tells us that greater investment now will mean smaller 

expenditure down the line. This has already been retrospectively 

validated by data released this month from one of the largest 

PEPFAR-funded treatment sites in South Africa, which demonstrated even further cost savings associated with an incredible 

impact of ARV therapy on boosting our response to other health 

challenges such as TB and maternal and child health. 

On maternal and child health, earlier this year HIV was described by The Lancet, the world’s leading medical journal, as the 

greatest cause of paralysis in efforts to address maternal and child 

mortality in sub-Saharan Africa, a paralysis that has been alleviated by PEPFAR’s provision of ARV services to at least 1.7 million 

women and children in the region, as well as a provision of prevention and testing services to millions more. 

An analysis that I got from the Journal of AIDS last year, which 

I will be happy to share with you, also demonstrated the scale-up 

of ARC has increased access to reproductive health services across 

the board—not just women living with HIV. 

President’s Obama’s Global Health Initiative is welcome in its 

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ices and an increased focus in maternal and child health. However, 

the lack of a sufficient correlating increase in funding to support 

this expansion, such as the fulfillment that will come at the cost 

of HIV, TB, and malaria programs. Any slackening of efforts to 

scale-up HIV treatment will scale back progress in all other areas 

of health and development identified as a priority by the GHI and 

will push us toward a loss at a time when we are more poised than 

ever to win. 

Unfortunately, the trend toward flatlining PEPFAR funding has 

already begun to do this. The Global Fund rotation requested by 

President Obama was $50 million less than what was given last 

year, and even with the current known level of $1.1 billion, still 

falls far short of the $2 billion per year that was authorized by the 

Lantos-Hyde legislation. 

We are not worried about money for its own sake but the impact 

of these financing decisions on our communities. We are worried 

that given these trends of flatlining, the 2009 directive to Uganda 

PEPFAR centers is namely that new patients could only be enrolled when others died or lost a follow-up might be repeated elsewhere in the future and wreak similar havoc. 

Doctors Without Borders has already reported increasing treatment of migrants at many of its sites in Mozambique where it 

notes that PEPFAR has warned of an annual 10–15 percent reduction in the ARV supplies over the next 4 years. Similar concerns 

have been reported in other countries. 

These developments seriously threaten to undo our progress in 

the fight against HIV. I would like to emphasize that we, of course, 

appreciate that the U.S. cannot do it alone. Advocacy and increased 

funding has been directed to a wide variety of governments. However, we do have to recognize that much like the establishment of 

PEPFAR changed the landscape of global AIDS response for the 

better, so the current slackening of U.S. Government efforts on 

scaling up HIV treatment is leading a regression back to the landscape where HIV was a death sentence because the price tag of life 

was deemed too high by governments. 

But the longer-term price tag will be even greater. The World 

Bank warned us last year that responding to immediate fiscal pressure by reducing spending on HIV treatment and prevention will 

reverse recent gains and require costly offsetting measures over the 

long term. It would be sad to see this come at a time when we are 

poised to turn the tide and when advocacy to hold national governments accountable for their contribution to the fight against AIDS 

is rapidly gaining momentum. 

In the African region over the past 15 months, civil society organizations have intensified efforts to scrutinize government budgets 

and expenditure and advocate for increased transparency and accountability. 

Yesterday, more than a dozen countries across the region took 

part in the first ever regional day of action on health funding. 

Thousands of people took to the streets in public demonstrations, 

health press conferences and public meetings all geared as calling 

on our governments to increase the domestic investment in helping, 

including HIV treatment, and as global leaders to fully replenish 

the Global Fund. 

75

This advocacy drew in a remarkable variety of partners under 

the leadership of NGOs working on HIV, thus demonstrating that 

the extensive community networks and movements that have been 

created through the HIV response present extraordinary platforms 

for mobilization and national government accountability, which will 

be severely undercut if funding retreat persists. 

We also note that we have seen positive government response 

from countries around the region. For example, in Kenya the 2010–

2011 budget for HIV treatment has doubled compared to the previous year due in large part to the Kenya PEPFAR partnership 

framework. In South Africa, the HIV budget showed a 3 percent increase this year. Following advocacy in Swaziland earlier this year, 

the government exempted the Ministry of Health from a sweeping 

budget that affected all other sectors. And we have heard earlier 

from Ambassador Goosby about the positive developments in Nigeria. 

Some of the poorest countries in the regions, such as Rwanda, 

Malawi, and Tanzania are leading the region when it comes to the 

domestic investment in health. Rwanda and Botswana are two of 

only eight countries in the world where universal access to treatment has been achieved. 

All of this goes to show that the vision originally embraced by 

this committee with establishment of PEPFAR and the LantosHyde legislation is entirely attainable but the key to determine 

success as we move ahead is political will. 

The crucial bottlenecks that we face with the future progress in 

the fight against HIV are not related to economics or to science but 

to political priorities. When the Lantos-Hyde Act was passed 2 

years ago, you took a very definitive landmark step toward realigning these political priorities and gave people living with HIV all 

around the world, as well as the communities, great hope that finally, a lasting precedent had been set for an energized global response to HIV, which would set the tone for a much broader response from all countries, and influence responses to other health 

needs as well. This has already been seen. 

Next week as mentioned earlier, donors will meet in New York 

to determine the fate of the Global Fund which requires a minimum of $20 billion U.S. dollars over the next 20 years. The United 

States could transform the replenishment with a promise of a bold 

3-year pledge at the levels authorized through Lantos-Hyde of up 

to $2 billion per year. 

I am here today to urge you to make this happen or to help make 

this happen, and best meet global efforts to making history by winning the fight against AIDS. 

Third, as you move toward a more long-term strategy for 

PEPFAR, it is my hope that you will recognize that sustainability 

will be achieved not by relaxation, but rather by intensification of 

efforts and investment because while this might cost us more 

today, evidence clearly shows that it will save us much more tomorrow. And that is the true basis of sustainable development. 

So I hope this committee will help us make a decision for tomorrow. 

Thank you. 

[The prepared statement of Ms. Akugizbwe follows:]

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Chairman BERMAN. Thank you for reminding us of the dangers 

of backsliding. 

Dr. El-Sadr. 

STATEMENT OF WAFAA EL–SADR, M.D., M.P.H., DIRECTOR, 

INTERNATIONAL CENTER FOR AIDS CARE AND TREATMENT 

PROGRAMS (ICAP), MAILMAN SCHOOL OF PUBLIC HEALTH, 

COLUMBIA UNIVERSITY 

Dr. EL-SADR. Good morning, and thank you for the opportunity 

to testify today at this very important hearing. 

I have personally been working in the field of HIV medicine since 

the very beginning of the epidemic when I was working at Harlem 

Hospital in New York City. And over the past decade, I have spent 

a great deal of my time working on PEPFAR-supported HIV and 

related capacity building, program development, and implementation in sub-Saharan Africa. 

As mentioned, I serve as director of ICAP, which is situated at 

Columbia’s Mailman School of Public Health, an institution with a 

long history of work, not just in HIV, but also in maternal mortality and child health. 

ICAP is a PEPFAR-implementing partner that supports more 

than 1,200 health systems in 15 countries in Africa today, and to 

date, it has supported services for over one million HIV-infected 

adults and children in a family-focused, women-centered approach. 

Roughly half of these individuals have initiated treatment. More 

than a million pregnant women with HIV have received HIV care 

for their own health, as well as prevention of transmission to their 

babies. Other supports include integration of TB/HIV services, HIV 

testing counseling, laboratory support, amongst many others. It 

has also supported the dynamic evaluation methods to inform programs and to ensure quality of the programs. 

We have witnessed firsthand the impact of PEPFAR on individuals, families, and communities, the rapid expansion of host country capacity, and the remarkable goodwill generated by PEPFAR 

for the U.S. and its people. Yet the work is far from done. The success of PEPFAR is widely acknowledged by the millions who have 

benefited from its program. Thus it is sometimes puzzling when 

one hears some misunderstandings regarding PEPFAR. I will briefly address these through the lense of my own experience and observations. 

First, some claim that PEPFAR works in isolation disconnected 

from country ownership. My experience says otherwise. PEPFAR is 

demand-driven at the community and host government levels. The 

work has been planned and implemented in partnership with Ministries of Health, regional district and facility health teams, as well 

as nongovernmental organizations, including faith-based organizations and with the affected communities. 

PEPFAR implementers play important and complementary roles 

in the scale-up of these programs, all contributing to the national 

AIDS control programs developed within the countries themselves. 

U.S. agencies, such as CDC and USAID, play key roles in forming 

these efforts under other coordination and guidance. 

Second, some claim that PEPFAR-supported programs have been 

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tegrated and linked to established services within the countries. 

Again, my own experience differs from this perception. The majority of health facilities deliver integrated HIV and primary care 

services right where these services are provided, including linkages 

to other key services such as reproductive health. 

In Nigeria, for example, ICAP supports PMTCT services for pregnant women within existing antenatal clinics. In Rwanda, ICAP in 

collaboration with the Rwandan Government, has supported integration of TB and HIV services and synergies between these two 

programs. 

In Ethiopia, in collaboration with the regional health bureaus, 

ICAP supports scale-up of routine HIV screening for all in-patients 

and out-patients at health facilities, including testing of mothers 

and babies integrated in immunization clinics. And there are many, 

many other examples. 

Fundamentally on the ground, there is no distinction between 

Global Fund and PEPFAR funding. The inputs are all integrated 

at the delivery site. 

Third, some claim that PEPFAR has had limited contributions to 

the country’s health systems, but the evidence says otherwise. In 

many of the countries where ICAP works, it has supported the development of tiered laboratory systems as we heard before. Good 

national regional local laboratories provide training and 

mentorship to staff. Health work toward innovations have also 

built up on the skills and morale of tens of thousands of existing 

health care workers in new countries through training and 

mentorship. 

Pharmacies across the continent have been supported through 

the provision of infrastructure, training, mentorship, capacity 

building for stock management and many, many other inputs—all 

of them contributing to stronger health systems that can respond 

to HIV as well as to all other health threats. 

A fourth misconception is that evidence of PEPFAR’s impact is 

difficult to discern. In reality, a key attribute of PEPFAR is its 

focus on concrete measurable outcomes, an approach that should 

serve as a model for other health and development programs. Without a doubt, PEPFAR has saved millions of lives and has preserved 

families and communities through access to HIV treatment. More 

than 7 million pregnant women have received counseling and treatment to prevent HIV transmission. 

Expansion of prevention counseling programs for male circumcision for HIV prevention are taking off in several countries. Overall, 

there is encouraging information indicating a 25 percent decrease 

in new HIV infections. 

Remarkably, with the expansion of HIV treatment, we are now 

witnessing a decrease in death rates in the most severely affected 

countries, including South Africa and Botswana. Different contributions to other health outcomes beyond HIV can also be noted. 

ICAP-supported programs in Nigeria offer pregnant women insecticide-treated bed nets for malaria prevention, water purification systems and ‘‘mama packs’’ to encourage safe pregnancy and facilitybased deliveries thus impacting maternal and child health. 

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Renovation of antenatal clinics, labor and delivery wards in support of orphans and vulnerable children are just a few examples of 

the broad impact of PEPFAR on the health of children. 

Encouraging evidence from South Africa shows a decrease in 

under five child deaths with expansion of HIV treatment to women 

in one community. 

But we are at a critical point in the response to the HIV epidemic. Scale-up of HIV treatment in PEPFAR-focused countries 

has been phenomenal, but it has only reached about a third of 

those in urgent need. Desperately ill men, women, and children living in communities near and far continue to line up at clinics in 

urgent need of services. For these individuals, the emergency is far 

from over. 

In addition, the more we learn about HIV, the clearer it becomes 

that earlier diagnosis and earlier treatment is more successful, and 

most importantly, more cost effective. 

New WHO guidelines support earlier treatment for adults, and 

it is now recommended that all children with HIV receive treatment. Similarly, a global consensus has arisen that all pregnant 

HIV-infected women must be reached if we are to eliminate HIV. 

There is also evidence that treatment for persons with HIV can 

prevent them from developing tuberculosis, a leading complication. 

Here is a chance to impact the TB epidemic in countries hit hard 

by the dual epidemics of HIV and TB. However, despite the scientific evidence, some national programs are reluctant to expand 

HIV treatments and the achievements of all of these benefits are 

outdone due to resource constraints. 

Another critical need is to scale-up evidence-based prevention 

programs, as well as to engage marginalized groups like men who 

have sex with men, injection drug users and commercial sex workers in both care and prevention services. Recent guidance from 

OGAC in terms of emphasis on addressing gender equity and support for harm reduction, including syringe exchange programs, go 

a long way to reinvigorating HIV prevention efforts. 

Thus, we are poised now with many of the new tools that you 

heard about earlier today to have a profound impact on stemming 

the epidemic and preventing new infections. 

There is little doubt that PEPFAR can and does provide a platform for addressing some of the key priorities of President Obama’s 

Global Health Initiative. Rather than reinventing the wheel or 

starting from zero, we can build on the platform established by 

PEPFAR at the tens of thousands of health facilities and under 

partnerships already established within the many communities. 

However, if we stall the expansion of PEPFAR in the name of a 

greater balance in global health spending, then we risk limiting advances in maternal and child survival as well as many other advances that go beyond HIV/AIDS per se. 

This committee envisioned a scale-up of resources when it reauthorized PEPFAR and set bold targets and new policies that would 

move us toward a world without an AIDS crisis. But the potential 

to truly turn the tide against the HIV epidemic and to achieving 

the durable impact, we all desire will not be realized if current 

funding crisis is not addressed. People will be turned away from 

clinics, services will be rationed, women and children and their 

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families will suffer. The optimism we have witnessed will evaporate and this remarkable potential will be squandered. 

Time is of the essence. The sooner we continue the scale-1up of 

HIV treatment and prevention, the more lives will be saved, the 

more tuberculosis cases can be prevented, the more families, communities and livelihoods will be preserved. Greater investments 

aiming at universal access, continued commitment to research in 

conjunction with an emphasis on building capacity and meaningful 

partnerships can change the trajectory of the HIV epidemic in the 

most severely-affected countries. It can also contribute substantially to the overall health and well-being of women and children 

and communities. 

Strong U.S. leadership and partnership with the affected countries and communities, as well as other donor nations can bring 

this goal within our reach. 

Thank you. 

[The prepared statement of Dr. El-Sadr follows:]

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Chairman BERMAN. Thank you for that testimony. 

I am now going to recognize Ambassador Watson for 5 minutes. 

We are told there will be votes on the House floor in the next 10 

or 15 minutes. So I think this will be our last shot. 

Ms. WATSON. Thank you so very much. You did mention in your 

testimony, and I missed the other witnesses, but our administration really would like to now focus on women and girls. They tend 

to be victimized more so in many different ways you mentioned. 

What is the common treatments and thinking in terms of securing 

the health and reducing the risk for women and girls? 

Dr. EL-SADR. There are many, many opportunities to do that, 

and some of them are ongoing. There clearly is the effort to 

prioritize the needs of women in the context of PEPFAR. For example, in the expansion of treatment, almost 60 percent of individuals 

receiving treatment through PEPFAR are women. In addition, the 

expansion of reach for prevention of mother-to-child transmission 

in enhancing the potential for a safe pregnancy and safe delivery 

is actually very profound in terms of trying to address the needs 

of these women. 

Lastly, I think the engagement of women in the context, of 

course, of taking care of their own families by providing them with 

all the resources that they need, recognizing that women are the 

central fulcrum for the health of the families themselves is also a 

very important contribution of what—the ongoing work of 

PEPFAR. 

Ms. WATSON. I understand that myths are flying all over the 

place, and there are certain beliefs in certain areas of Africa, in 

particular South Africa. And I go often to South Africa, but I heard 

that there is a belief in the southern tip that if men had sex with 

babies, it would relieve them of AIDS. 

What do we have to do—and, you know, women cannot refuse 

their men when they want to have sex. That is a belief in some 

areas. How do we go about changing the way, the old customary 

ways, of believing when it comes to women and girls? And I am 

just wondering what we can do to enhance the obliteration of those 

kinds of cultural mythical beliefs. 

Ms. AKUGIZIBWE. Well, you know. I think one of the reasons why 

HIV—the HIV epidemic was exceptional is because it has highlighted a lot of these long-standing cultural challenges. And it has 

really brought in to bear the public health context, but underlying 

that are much more deep-rooted social issues. 

And speaking from my experience in working with an NGO that 

does community training and community advocacy, issues such as 

this are a fundamental component of all the training that we do 

related to HIV, because unless we can address underlying dynamics, we can’t actually overcome the HIV epidemic. 

And I think that possibly one of the most valuable things that 

the HIV response has brought us is the creation of these extensive, 

far-reaching, community-based networks that give us space to start 

discussing a lot of otherwise issues that would otherwise never 

have had the opportunity to explore. 

But to also touch on the earlier point about women and girls and 

how they fit into this, one of the things that I had mentioned is 

that HIV in South Africa, for example, is the cause of more than 

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40 percent of maternal mortality. And so for us to separate these 

two things can get a bit misleading sometimes. And I think what 

we need to be doing is seeing how we can strengthen the value that 

HIV response has brought to efforts to advance women’s health 

while adding resources to us to expand, to address a wider range 

of issues that don’t necessarily fall within HIV. 

Ms. WATSON. The most successful programs that I saw in areas 

of South Africa were the programs where we gave them the resources and let them, through their own techniques, deal, and they 

can talk a small amount of money and stretch it. And so I believe 

that we can better serve the people we are targeting with our resources by going through the structure that is already it socially 

and culturally. 

I yield back. You have got 30 seconds, Mr. Chairman, to give to 

someone else. 

Chairman BERMAN. The gentlelady has yielded back. The votes 

have just been called, so we have about 10 more minutes here. 

Can I just arbitrarily say let us take 4 minutes a witness rather 

than 5? 

Mr. Smith, 4 minutes. 

Mr. SMITH. Thank you very much. 

Chairman BERMAN. 4 minutes. 

Mr. SMITH. Sorry I missed our distinguished witnesses. I was at 

a press conference with Jim Moran on a child abduction case. The 

chairman was kind enough to place on the calendar yesterday a 

very important resolution that calls for the release of American 

children who have been abducted to Japan. So I do apologize for 

missing that. 

I would ask unanimous consent that the ranking member’s statement, Ileana Ros-Lehtinen, be included in the record. 

Chairman BERMAN. Without objection. 

[The prepared statement of Ms. Ros-Lehtinen follows:]

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Mr. SMITH. As well as that of Joseph O’Neill and Michael Miller, 

who have transcripts of testimony that——

Chairman BERMAN. Will be included. 

Mr. SMITH [continuing]. An op-ed that I wrote for the Washington Post, and the African First Lady’s declaration. 

Chairman BERMAN. It will all be in there. 

Mr. SMITH. I appreciate that. 

Let me just very briefly raise for all my colleagues, I am sure our 

distinguished witnesses know all about this as well, the Call for 

Action at the Millennium Development Summit last week. The 

First Ladies of Africa—there were nine in total, and I believe there 

were seven in the room—I was at the roundtable discussion—they 

made a very, very important contribution, as they always do. Part 

of their statement was good nutrition is a requirement, a way to 

advance the Millennium Development Goals. There is a direct link 

between malnutrition, hunger and poverty, MDG 1; child mortality, 

MDG number 4; maternal health, MDG 5; and AIDS and other infectious diseases, MDG number 6. Equally important, poor nutrition has a causal effect in eliminating achievement of education, 

MDG 2, and gender equality, MGD number 3. 

They went on to say in their declaration, we now know how to 

reduce malnutrition through the life cycle by a number of simple, 

targeted and cost-effective solutions. The critical window of opportunity is the 1,000-day period from conception to 2 years old. Fortified staples; good infant-feeding practices; more nutritious, complementary foods are some of the tools available to help permanently break the intergenerational cycle of malnutrition. New ways 

to mobilize business, develop agriculture and food security, improved feeding and health practices are available. And then they 

go on in their declaration to make a number of very important mutually reinforcing statements. 

I am wondering from our distinguished witnesses how you see 

this playing out, because as we did in the last PEPFAR reauthorization, we made sure that nutrition was included. I mean, I recall 

once when I was taking antibiotics, and I wasn’t eating as much, 

it causes a backlash even from something as simple as doxycycline 

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empty stomach, in a malnourished person, how that could not only 

be difficult, but also counterproductive. 

Obviously nutrition is important. But this idea of the first 1,000 

days from the moment of conception, could you speak to that, if you 

would? 

Dr. EL-SADR. I will start. 

I think from day 1 in terms of implementation of PEPFAR-supported programs, there had been attention given to nutrition and 

clearly integration of and provision of nutritional supplements to 

individuals who need it, as well as often to families of these individuals. So that has been part and parcel of the work on the 

ground. 

In addition, there has also been very innovative programs to try 

to enable people living with HIV and their families to support 

themselves and to grow their own foods. There are some very—programs that I am aware of and some of them we have supported in 

terms of income generation and generating food and nutrition for 

the families and for the communities. 

I think that the third point I want to make in terms of nutrition 

is the importance of, obviously, within the PMTCT programs, programs for prevention of mother-to-child transmission, there are situated right in antenatal care to provide counseling to these women 

regarding nutrition in terms of their own health as well as also in 

terms of feeding of their babies after their babies are born. 

So there is a package that includes—that focuses on nutrition 

that is part and parcel of several components of the work that we 

do, whether it be in the PMTCT antenatal setting, in the postnatal 

setting, or just in terms of the ongoing care and treatment activities. 

Ms. AKUGIZIBWE. Your question reminds me of a conversation we 

had with the Canadian national AIDS coordinator and someone living in a low-income part of Nairobi. 

Chairman BERMAN. Our problem is the 4 minutes has expired. 

I am sorry to do this, but maybe you can worm it into the next answer here. 

The gentlelady from California, Ms. Lee, is recognized for 4 minutes. 

Ms. LEE. Thank you, Mr. Chairman. 

Let me just say the importance of women’s voices and the work 

of women, the empowerment of women is so key to stamping HIV 

and AIDS from the face of the Earth. You both are really wonderful 

examples of why women have to be at the lead in this effort, so 

thank you very much. 

I just wanted to ask you one question about—and I mentioned 

earlier that I was appointed as a Commissioner on the Global Commission on HIV and the Law. We will be meeting next week in 

Brazil. I wanted to find out from you in terms of—and part of our 

job is to look at some of the legal impediments for vulnerable populations: Gender violence, men having sex with men, commercial sex 

workers. What you would say should be some of your top priorities 

that we should consider? 

Ms. AKUGIZIBWE. I think the issues that you have highlighted 

around vulnerable groups and the way that legal frameworks 

present the ability to access health services, such as sex workers, 

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such as men who have sex with men, are some of the biggest challenges we are facing in the African region. 

Additionally, the introduction of laws that give punitive sanctions for what is called willful HIV transmission, which is often interpreted in many ways. For example, a woman who cannot negotiate safe sex with her husband and never had sex without a 

condom, but is HIV positive could then be prosecuted under these 

laws for willful transmission, and that has happened in several 

countries. I would be happy to provide you with more detail on 

some of the work that is highlighting these issues. 

I think another, much bigger challenge is also around the way 

that legal systems recognize other socioeconomic rights, such as nutrition, and it affects the success of HIV programs. And I think the 

failure by many countries to recognize basic socioeconomic rights is 

impacting our ability to successfully implement HIV programs, especially when it is compounded by the flatlining of budgets that we 

are seeing in many HIV programs as a result of global declines and 

funding. You have situations where people are willing to take 

treatment that is readily available, an anecdote I referred to earlier, but are not able to start it because they don’t have food, because the HIV program, because of its reduced budget, has cut food 

packages out of the overall package of services, and the government hasn’t stepped in to fill that gap. 

So those are the social challenges. 

Chairman BERMAN. The gentlelady has yielded back her time. 

All right. In that case I recognize for a couple of minutes—we do 

have to leave for vote—but for 3 minutes the gentlelady from Texas 

Ms. Sheila Jackson Lee. 

Ms. JACKSON LEE. Thank you very much, Mr. Chairman, and I 

thank the witnesses. 

If I understand, the earlier testimony by Dr. Goosby and other—

Ambassador Goosby, rather, and a number of the witnesses on the 

first panel was to affirm the importance of PEPFAR, Global Health 

Initiative. I want to affirm the importance of sustainability and to 

comment that when we have made progress, but still see sub-Sahara Africa with 67 percent of worldwide HIV infections and infections still occurring in 2008, it means that we still have work to 

do. And I would like to make our program focus itself more clearly 

on sustainability and a combined effort as I know we are with malaria and tuberculosis. 

So I would like to ask Ms. Akugizibwe, if I could, about the point 

that you just made about more funding and the lack of food packages, because at one time there was some dialogue that it was a 

nutrition issue. We know that we have dispelled that myth, but 

there is no doubt that you need to have nutrition, and you need to 

have a basis of healthiness, diet, so that you can continue to have 

people live longer if they are already HIV-infected. 

Would you just highlight and emphasize how we need to use our 

monies for sustainability in this fight against HIV/AIDS? 

Ms. AKUGIZIBWE. I think, as I mentioned in my testimony, that 

sustainability, a key component of that is recognizing that investments now are beginning to pay off and will continue to do so at 

a greater scale if they are sustained. Although we are still seeing 

infections, we are also seeing for the first time a decline in the rate 

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of new infections, especially in sub-Saharan Africa, and this is due 

in large part to the investment that has been made into treatment. 

And I can mention this investment in HIV programs and treatment has highlighted a lot of other social issues, such as gender violence, such as nutrition. And what is more interesting is that the 

HIV response and the civil society mobilization that just happened 

around that has been probably the most effective vehicle for mobilizing advocacy around our own Government’s accountability in addressing these other challenges. 

So when we talk about government’s investment in HIV treatment, it also gives us an opportunity to raise the investment in 

food and other——

Ms. JACKSON LEE. Can I ask Dr. El-Sadr to give a comment in 

my remaining short seconds? Can you just comment very quickly 

on that question, sustainability? 

Dr. EL-SADR. I think that we have had remarkable success, and 

I think, again—and it should be recognized even in the hardest hit 

countries. So the effect has been profound. 

There are investments today by the countries themselves in 

terms of the response to HIV/AIDS. So it is not a unilateral U.S.-

supported response or largely from donors, but it is joint investment from the countries and from the external resources. 

The conversations that are happening within the countries now 

are to identify and recognize the national—the country contributions as well as the external investments. 

I think an investment today—what we need to do today will absolutely ensure the durability of this response and the ability to actually sustain it beyond the next 5 years. So stalling on the commitment today can have far-reaching impact on the ability to actually have a durable and sustainable response. 

Ms. JACKSON LEE. Thank you very much. 

Thank you, Mr. Chairman. 

Chairman BERMAN. The time of the gentlelady has expired. 

You were great witnesses. Thank you very much for coming, and, 

without objection, the opening statement of the gentleman from 

New Jersey Mr. Payne will be included in the record. 

The committee is now adjourned. Thank you. 

[Whereupon, at 11:55 a.m., the committee was adjourned.] 

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A P P E N D I X 

MATERIAL SUBMITTED FOR THE HEARING RECORD

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MATERIAL SUBMITTED FOR THE RECRORD BY THE HONORABLE CHRISTOPHER H. 

SMITH, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY


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