U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001

77–846 PDF 2002

S. HRG. 107–330

HALTING THE SPREAD OF HIV/AIDS: FUTURE

EFFORTS IN THE U.S. BILATERAL AND MULTILATERAL RESPONSE

HEARINGS

BEFORE THE

COMMITTEE ON FOREIGN RELATIONS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

FEBRUARY 13 AND 14, 2002

Printed for the use of the Committee on Foreign Relations

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate

COMMITTEE ON FOREIGN RELATIONS

JOSEPH R. BIDEN, JR., Delaware, Chairman

PAUL S. SARBANES, Maryland

CHRISTOPHER J. DODD, Connecticut

JOHN F. KERRY, Massachusetts

RUSSELL D. FEINGOLD, Wisconsin

PAUL D. WELLSTONE, Minnesota

BARBARA BOXER, California

ROBERT G. TORRICELLI, New Jersey

BILL NELSON, Florida

JOHN D. ROCKEFELLER IV, West Virginia

JESSE HELMS, North Carolina

RICHARD G. LUGAR, Indiana

CHUCK HAGEL, Nebraska

GORDON H. SMITH, Oregon

BILL FRIST, Tennessee

LINCOLN D. CHAFEE, Rhode Island

GEORGE ALLEN, Virginia

SAM BROWNBACK, Kansas

MICHAEL B. ENZI, Wyoming

EDWIN K. HALL, Staff Director

PATRICIA A. MCNERNEY, Republican Staff Director

(II)

CONTENTS

HALTING THE SPREAD OF HIV/AIDS: FUTURE EFFORTS

IN THE U.S. BILATERAL AND MULTILATERAL RESPONSE

FEBRUARY 13, 2002

Page

Dobriansky, Hon. Paula, Under Secretary for Global Affairs, Department

of State, Washington, DC .................................................................................... 29

Responses to Additional Questions Submitted for the Record by the

Committee to Under Secretary of State Paula Dobriansky ...................... 48

Lyman, Hon. Princeton, working group co-chair, Center for Strategic and

International Studies Task Force on HIV/AIDS; executive director, Global

Interdependence Initiative, Aspen Institute, Washington, DC ........................ 78

Prepared statement ...................................................................................... 82

Natsios, Hon. Andrew, Administrator, U.S. Agency for International Development, Washington, DC ......................................................................................... 20

Prepared statement ...................................................................................... 24

Okaalet, Peter, M.D., Africa director, Medical Assistance Program International, Nairobi, Kenya ..................................................................................... 98

Prepared statement ...................................................................................... 102

Piot, Dr. Peter, executive director, UNAIDS, Geneva, Switzerland .................... 53

Prepared statement ...................................................................................... 56

Ray, Dr. Sunanda, director, Southern Africa AIDS Information Dissemination

Service, Harare, Zimbabwe ................................................................................. 88

Prepared statement ...................................................................................... 92

Thompson, Hon. Tommy G., Secretary, Department of Health and Human

Services, Washington, DC; Accompanied by Claude Allen, Deputy Secretary ..................................................................................................................... 11

Prepared statement ...................................................................................... 14

RESPONDING TO AFRICA’S HIV/AIDS CRISIS:

ROLES OF PREVENTION AND TREATMENT

FEBRUARY 14, 2002

Kim, Dr. Jim Yong, director, Program in Infectious Disease and Social

Change, Harvard Medical School, Boston, MA .................................................. 158

Prepared statement ...................................................................................... 161

McCray, Dr. Eugene, director, Global AIDS Program, National Center for

HIV, STD, and TB Prevention, Centers for Disease Control and Prevention,

Atlanta, GA ........................................................................................................... 119

Prepared statement ...................................................................................... 123

Peterson, Dr. E. Anne, Assistant Administrator, Bureau of Global Health,

U.S. Agency for International Development [USAID], Washington, DC ......... 130

Prepared statement ...................................................................................... 134

Sachs, Dr. Jeffrey, director, Center for International Development, Harvard

University, Cambridge, MA ................................................................................. 146

Prepared statement ...................................................................................... 149

Vorster, Martin J., Mahyeno Tributary Mamelodi, Pretoria, South Africa ........ 174

Prepared statement ...................................................................................... 177

(III)

(1)

HALTING THE SPREAD OF HIV/AIDS: FUTURE

EFFORTS IN THE U.S. BILATERAL AND MULTILATERAL RESPONSE

Wednesday, February 13, 2002

UNITED STATES SENATE,

COMMITTEE ON FOREIGN RELATIONS,

Washington, DC.

The committee met at 11:12 a.m., in room SD–419, Dirksen Senate Office Building, Hon. Joseph R. Biden, Jr. (chairman of the

committee), presiding.

Present: Senators Biden, Feingold, Smith, and Frist.

The CHAIRMAN. The hearing will come to order.

Mr. Secretary, who is not here, Madam Secretary, Mr. Natsios,

thank you for coming this morning to speak to the committee about

what has become one of the most, if not the most, pressing global

health concerns of our time, and that is the spread of HIV/AIDS.

As you know, this is the first in a series of hearings that this

committee will hold on HIV/AIDS. Senator Feingold will chair a

hearing on HIV/AIDS in Africa tomorrow afternoon, and others on

this committee will chair hearings on the same issue after the recess as it relates to the problem in other parts of the world.

I do not have to tell any one of you how devastating this epidemic is. The disease has killed more people than the bubonic

plague of the Middle Ages. And it is spreading. Five million people

were infected with HIV/AIDS in the past year alone. It has ravaged

the continent of Africa and is spreading like wildfire.

There are countries in the region that have infection rates of over

30 percent. Africa is not alone. The number of people affected in

India could soon be greater than that of any African country. China

has recently acknowledged its problem, and the countries of the

Caribbean have infection rates second only to those in Africa.

And lest we in the north begin to think that we are insulated

from this problem, all we have to do is look at the increase in the

infection rate in Russia—up 1,300 percent in the last 5 years—to

know that nowhere on the planet are we invulnerable to this disease.

Ladies and gentlemen, we are facing a disaster of epidemic proportions in my view. This disease could wipe out a generation. It

has already created millions of orphans in Africa. Who is going to

care for those children when the parents and relatives are dead?

Who will educate them when their teachers are dying of AIDS faster than universities can train them? Where will they go for medical

2

attention in countries where the health care system is underfunded, overburdened, and understaffed due to HIV/AIDS?

I do not think that the security, social, and economic implications

of the spread of AIDS have been fully appreciated by most. I submit that we must begin taking them much more seriously. The consequences of this disease running unchecked throughout the world

are everything from 3 decades of development gains lost to rampant instability and state failure in parts of the world. The potential

for political instability due to the deaths of political and military

leaders is a cause for concern in newly emerging democracies, according to reports. Gross domestic products are set to decline anywhere from 8 to 20 percent depending on how many years out one

calculates the loss.

This cannot be allowed to happen. We must attack this disease

on all fronts, using every technique feasible from prevention to care

to treatment—or we will fail.

It is imperative that the United States engage in a considered coordinated strategy in its bilateral assistance programs. We cannot

afford to waste a single dollar with duplicative, overlapping efforts

among various U.S. Government agencies. The problem is big

enough for more than one of our agencies to constructively contribute something, but it is far too big for every agency to focus its

efforts on doing the same thing.

One important tool to contain the spread of infectious disease

and to spot biological terrorism efforts is effective disease surveillance. Senator Helms and I plan to introduce a bill to bolster U.S.

assistance to developing nations to improve their national disease

surveillance capabilities so that the world can track these outbreaks. I know that Senator Frist and Senator Kennedy have

worked extensively on this matter as well regarding the infrastructure.

I have administration promises to work with us on this legislation, and I think it is important that we make a real effort in this

area. But that should be only part of the necessary response if we

are to have any hope of containing HIV/AIDS.

There is a lot more to say, but I and my colleagues are eager to

hear testimony and ask questions about the United States’ efforts

to stop the spread of HIV/AIDS throughout the world.

Before we begin, though, let me say this. Without leadership

both here and abroad, none of our efforts will be successful. We

need strong leadership here in the United States to devote the necessary resources to both our bilateral programs and to the Global

Fund. We need leadership from our donor partners for the same

reason, and we need leadership from recipient countries. I do not

believe for a moment that any assistance program for HIV/AIDS

can be successful without committed, sustained public leadership

from recipient countries. In the absence of leadership at the highest level, any program that donor countries fund or support will,

at best, generate mediocre results, and at worst, be doomed to failure.

Again, I thank you all for coming and I look forward to hearing

your testimony.

At one point from the perspective of what we are all focusing on

now, I would suggest that—and we will make available a report—

3

my colleagues and the country look to the fact that even from purely a defense standpoint, purely from the standpoint of U.S. security

interests, the Defense Department as well as the CIA, has listed

this as one of the great threats to U.S. security. This is not merely

a health problem.

Before we hear from our first panel, we have before us submissions from Senators Corzine and Durbin, and without objection, I

would like to enter their statements in the record so we can move

right to witnesses. There being no objection, it is so ordered.

[The prepared statements of Senators Corzine and Durbin follow:]

PREPARED STATEMENT OF SENATOR JON S. CORZINE,

U.S. SENATOR FROM NEW JERSEY

U.S. BILATERAL AND MULTILATERAL RESPONSE TO HIV/AIDS

Mr. Chairman, I commend you for holding this hearing today on a topic of immense consequence. As this Committee considers how best to respond to the global

HIV/AIDS pandemic, I want to bring special focus to the plight of women and their

families across the developing world.

Mr. Chairman, two decades after the start of the HIV/AIDS pandemic, AIDS kills

more people worldwide than any other infectious disease. And of the 40 million people now living with HIV/AIDS, nearly half are women.

Yet, despite twenty years of experience with this crisis, and at a time when the

incidence of sexually transmitted infections (STIs) is reaching epidemic proportions,

the only public health messages women receive about the prevention of HIV and

other STIs are about monogamy and condom use. While these are critical messages,

for many women these messages are, unfortunately, inadequate or unrealistic. They

may also be life threatening. Millions of women lack both the power within relationships to insist on condom use and the social and economic resources to abandon

partners who put their health at risk. And we also know that due to their biology,

women are four times more vulnerable to HIV infection than men.

Given these realities, there is no question that female-controlled HIV prevention

methods such as microbicides are vital to controlling the spread of HIV.

Microbicides are a new class of products currently under research and development

that are topically applied to prevent the transmission of HIV and other sexually

transmitted infections. If we want to defeat the AIDS virus, we must be committed

to developing new prevention tools, like microbicides, in the same way that we are

committed to the development of an AIDS vaccine. Women worldwide need this commitment.

Recognizing this, last year Senator Olympia Snowe and I, along with Senators

Cantwell, Leahy, Murray, Kerry, and Dodd, introduced S. 1752, legislation aimed

at redoubling federal efforts to develop safe and effective microbicides. Our legislation focuses on microbicides research efforts already underway at the National Institutes of Health and the Centers for Disease Control. However, I know that USAID

also does important work in this area, and I hope that this hearing can help ensure

greater coordination between relevant federal agencies as they seek to advance

microbicide research and development so that we can more quickly get these products to those women in greatest need. With a greater federal commitment to

microbicides research, leading microbicide research groups, including the Global

Campaign for Microbicides and the Rockefeller Foundation Microbicide Initiative,

estimate that a microbicide could be brought to market within the next five years.

Just yesterday, the Rockefeller Foundation released the findings of their two-year

study on the science and policy challenges in microbicide research. This new set of

studies conclude that even by the most conservative of estimates, microbicides have

the potential to dramatically prevent new infections and emerge as a critical tool

in our HIV prevention arsenal.

Without increased federal investment in microbicide research, however, we will

not achieve this goal. The Rockefeller ‘‘Pharmaco-Economics Working Group’’ of experts estimates that the cost of developing the existing pipeline of products would

be roughly $775 million over five years, with the expectation that this investment

would generate several safe, effective microbicides by 2010. However, the public and

private funding currently estimated to be committed over the next five years is

roughly $230 million. This leaves a shortfall of at least $545 million dollars.11If we

4

could muster public and private sector funds to meet this shortfall, what would be

the potential impact of this investment? Using conservative assumptions, researchers at the London School of Hygiene and Tropical Medicine, who worked with the

Rockefeller Foundation on these studies, estimate that a 60 percent efficacious

microbicide used in 73 lower income countries could avert 2.5 million HIV infections

over three years. 2.5 million fewer infections translates into a cost savings of $3.7 billion for already over-burdened governments in developing countries—$2.7 billion in averted

health care costs and $1 billion in productivity benefits.

So, Mr. Chairman, where are we now? The short answer is: not even close. In FY

2001, the National Institutes of Health invested only $34.6 million in microbicide

R&D—less than 2% of the Institute’s AIDS-related research budget. My bill—and

its companion legislation in the House—would greatly strengthen the federal commitment to microbicide research at NIH and elsewhere. Microbicides will give

women in this country and around the world one more way of protecting themselves

against the ravage of HIV/AIDS. We need to act now.

Thank you for your interest in this important matter.

PREPARED STATEMENT OF SENATOR RICHARD J. DURBIN

Mr. Chairman, I commend you for calling this very important hearing to discuss

U.S. efforts to address the global HIV/AIDS pandemic. Thank you for permitting me

to testify today. I look forward to working with the Committee to develop a strong

response to this crisis that will clearly state the Congressional commitment to halting the spread of this devastating disease around the world. I would like to present

to the Committee a comprehensive legislative proposal that I have developed in the

hope that we can begin in earnest a dialogue that moves this issue forward before

the year is out.

Yesterday, I introduced the Global Coordination of HIV/AIDS Response Act,

known as the Global CARE Act. As we all know, HIV/AIDS is a national security

issue, an economic issue, a health and safety issue, and most importantly a moral

issue. My bill will not solve all of the problems caused by the AIDS pandemic. But

it does set the bar where the need is, and I believe it does offer some innovative

ideas to address the global AIDS crisis in a strategic, coordinated, and accountable

manner.

It is critically important that we demonstrate the political will to act on this issue.

I think it would be productive for Congress to establish clear policy goals and funding targets that represent the real need. It is also our job to ensure that there is

accountability for the money that we appropriate, and that we are able to articulate

the results of our U.S. investment. It is my hope that by doing this we will secure

a serious, effective financial commitment that to date has been woefully inadequate.

The Global CARE Act is grounded in the principles of leadership and accountability.

The policy goals I have set forth in this bill are the following: better coordination

among the myriad of U.S. agencies active in the global AIDS fight; a more focused

strategic planning initiative that makes the best use of U.S. bilateral assistance; increased accountability for the health and policy objectives we seek to achieve with

our financial and human investment in AIDS-ravaged countries; the ability to mobilize the most effective human and capacity-building tools to provide some of the

building blocks that are needed; and a clear articulation of the broader issues that

need to be addressed to have a real impact on HIV/AIDS, including not just prevention but treatment and care, and not just health initiatives but also economic investments.

The Global CARE Act provides specific funding authorizations for the key agencies working on global AIDS, as well as for the Global Fund. Both bilateral and multilateral assistance is needed to address this problem. Before the Leadership and

Investment in Fighting and Epidemic (LIFE) initiative authorized USAID to conduct

activities specifically focused on global AIDS in FY2000, there was little direction

from Congress on this issue. And up until the United Nations and President Bush

specifically requested money for the Global Fund, there was little agreement about

what was needed. It is now time for Congress to step up to the plate and provide

some direction.

The authorized funding levels in the Global CARE Act represent a need that has

been well documented. The World Health Organization’s Macroeconomics and

Health Commission has determined that by 2007, the international community—

donor and affected countries—should be spending $14 billion in response to the

5

AIDS pandemic. Last year, the United Nations called for roughly $10 billion annually.

America has by far the greatest giving capacity, yet we devote the smallest percentage of our overall wealth to efforts aimed at alleviating global poverty and disease. Last year the United States gave one-tenth of 1 percent of its GNP to foreign

aid—or $1 for every thousand dollars of its wealth—the lowest giving rate of any

rich nation. By comparison, Canada, Japan, Austria, Australia and Germany each

gave about one-quarter of 1 percent—or $2.50 for every thousand dollars of wealth.

Many other countries give even more, at rates 8 to 10 times higher than the United

States. Based on its share of global GNP, the United States should contribute at

least 25 percent of the total AIDS response cost in 2003. Twenty-five percent of the

estimated $10 billion needed next year would be $2.5 billion. Hundreds of civic

groups and religious leaders have joined together, calling on Congress to provide at

least $2.5 billion to combat the pandemic.

The Global CARE Act establishes broad policy goals and activities that are embodied in an international HIV/AIDS Prevention and Capacity Building Initiative

and an International Care and Treatment Access Initiative. These goals and activities, which range from education, voluntary testing and counseling to helping preserve families and ameliorate the orphan crisis, are not parceled out to the various

agencies we know are actively engaged in this issue such as the U.S Agency for

International Development (USAID) and the Centers for Disease Control and Prevention (CDC). Rather this legislation generally relies on the existing authorities of

the agencies to carry out these broad activities with the requirement that they coordinate their activities with each other and with host country needs and host country plans.

The development of a coordinated, effective, and sustained plan for U.S. bilateral

aid in relation to multilateral aid and other nation’s bilateral aid is paramount. The

U.S. has the opportunity to provide the requisite leadership in this global effort

though operating strategically, and in an accountable and transparent manner.

To provide an incentive for such coordination, the bill establishes an interagency

working group charged with ensuring that global HIV/AIDS activities are conducted

in a coordinated, strategic fashion. Members of this working group include agencies

within the Department of State, specifically USAID; agencies within the Department of Health and Human Services, including the Centers for Disease Control and

Prevention, the Health Resources and Services Administration, and the National Institutes of Health; the Departments of Defense, Labor, Commerce and Agriculture,

and the Peace Corps.

It is my intention to create a policy working group with representatives from the

agency programs doing the real work. The working group will help to ensure that

the various agencies we fund to provide bilateral assistance are making the most

of the money we appropriate; that they are not duplicating efforts; that they are

learning from each others’ programmatic experience and research in order to implement the best practices; and that they are accountable to Congress and the American people for achieving measurable goals and objectives. In fact, the function of

this group is very similar to the interagency working group established in H.R.

2069, legislation that passed the House of Representatives last year.

The Global CARE Act very specifically directs the working group to report back

to the Senate Committee on Foreign Relations, the Senate Committee on Health,

Education, Labor and Pensions, and the Senate Appropriations Committee, and the

corresponding Committees in the House of Representatives, with the following information: 1) the actions being taken to coordinate multiple roles and policies, and foster collaboration among Federal agencies contributing to the global HIV/AIDS activities; 2) a description of the respective roles and activities of each of the working

group member agencies; 3) a description of actions taken to carry out the goals and

activities authorized in the International AIDS Prevention and Capacity Building

Initiative and the International AIDS Care and Treatment Access Initiative set out

in the legislation; 4) recommendation to specific Congressional committees regarding

legislative and funding actions that are needed to carry out the activities articulated

in the bill; and 5) the results of the HIV/AIDS goals and outcomes as established

by the working group. In my view, only by requiring very specific reporting requirements will the working group actually work.

The Global CARE Act includes a number of other provisions. Some have been discussed on the Hill, others have not. It authorizes a Global Physician Corps to utilize

the human capital we have in our working and retired physicians by providing a

mechanism for them to serve overseas where their expertise is so needed.

The bill authorizes a small amount for USAID to work on developing and implementing initiatives to improve injection safety. According to the World Health Organization (WHO), each year the overuse of injections and unsafe injections combine

6

to cause an estimated 8 to 16 million hepatitis B virus infections, 2.3 million to 4.7

million hepatitis C infections and 80,000 to 160,000 HIV infections. Together, these

chronic infections are responsible for an estimated 10 million new infections, more

than 1.8 million deaths, 26 million years of life lost, and more than $535 million

in direct medical costs.

It includes a new pilot program to provide a limited procurement of antiretroviral

drugs and technical assistance to programs in host countries. And it includes a very

important orphan relief and microcredit component that acknowledges that addressing the AIDS problem requires both an economic and social investment in women

and families.

I hope that the Committee will consider the framework and policy that I have developed as we work to introduce a unified proposal to address this problem. Tackling

this pandemic will take more than one good bill—it will take a concerted effort to

combine the best ideas and realistic initiatives to get the job done.

The CHAIRMAN. I would also like to acknowledge the presence of

a contingent from the African ambassadorial corps here today. As

you know, that continent has been ravaged by this disease and

their presence indicates a commitment by their countries to acknowledge and to deal with the spread of this disease.

Lastly I will say because of the diplomatic—how can I say—as

Kofi might say, the diplomatic niceties that have to be observed,

Kofi Annan, who has been leading in this area as well on the international stage, has been extremely cooperative with this committee. He was going to testify before the committee, but quite

frankly, I think it would have put him in a difficult position as the

head of the United Nations sitting down and being asked questions

by Senators.

So, we have come up with a diplomatic solution. He is going to

come and speak to us at 3 o’clock this afternoon at a coffee I have

invited many of my colleagues to attend, and we will treat it as we

would treat a head of state and/or a foreign minister coming, not

in terms of him being in a position of answering our questions, but

in terms of sharing with us his incredible sense of urgency about

what we must do and the part he thinks that we and others have

to play.

With that, let me yield to my good friend, the good doctor from

Tennessee, who has been a genuine leader, along with Senator

Feingold, on this issue.

Senator FRIST. Thank you, Mr. Chairman. I would just ask unanimous consent that my remarks be made a part of the record as

well.

The CHAIRMAN. Without objection.

Senator FRIST. But let me briefly thank both of my colleagues

who are here, the chairman for bringing this issue, HIV/AIDS, the

global pandemic, to this level with the presenters and the witnesses before us today, and also the chairman of the Africa Subcommittee. Over the last several years, we have worked side by

side in addressing this issue and many issues. He is holding the

hearing tomorrow which, in many ways, is a sequel and will build

upon the foundation today, again representing the commitment of

this committee, the Foreign Relations Committee, in addressing

what is the most devastating, destructive public health challenge

that we will have clearly had since the 1300’s, but probably of all

time.

Before coming to the United States Senate, I was a physician,

and because I did heart transplants and lung transplants, all of my

7

patients were on immunosuppression. The risk is not of heart rejection or of lung rejection, but because of the medicines we gave, it

was infectious disease. When a patient, after a successful transplant, got an infection, the infection would set in, he or she would

stop working, he or she would have to drop out of school, would

lose income to support the family, could no longer support their

children, could no longer participate in the community, a family

would become less secure and lost hope became the dictum. Well,

with that, all normal life would dissolve. That is one patient. That

is what I had the opportunity to see.

Two weeks ago, three weeks ago, I was in Africa once again, and

as we went from Uganda to Tanzania to Kenya, looking at HIV/

AIDS programs, exactly what is happening to that patient, that individual patient whose life is destroyed by this infectious disease,

this virus, is happening to a continent. That is really what we are

struggling to address. We will hear much more about how it is

being done structurally from our witnesses today.

Let me just close my opening remarks by really taking what we

all have to do and that is putting real faces on what we are addressing when we talk of statistics and 3 million people and 40 million people and the staggering growth.

In Nairobi, Kenya, I went to the Kabarro slum. Many people in

this room have been to the slum. It is right there, right in the city

itself, a population of over 750,000 people there. One out of five of

those are HIV/AIDS-positive. As you walk through the crowded

streets with all the shanties and the tin roofs, you are amazed that

you see just young children. You literally do not see people of middle age. You see some older people and you see 20, 30, or 40 young

people around them, but this whole middle generation is being

wiped out. We will hear more about the details, but it is just remarkable when you walk into that slum and you see that there is

nobody there middle-aged.

Teachers are gone. The military has been destroyed in many

countries. The workers, the providers.

In Arusha, Tanzania, I met Nema whose name means grace. She

sells bananas to survive and to provide for her year-and-a-half-old

son Daniel. When Daniel cried from the hunger, Nema kissed his

hand because she had nothing to give him but love, again suffering

from the ravages of HIV/AIDS.

Also in Arusha, there was Margaret whose symptoms first came

in 1990. When her husband died, despite her illness, she found the

strength to fight his family because of cultural norms there. The

property automatically goes to the husband’s, who has died, family.

Automatically it is stripped away. Thanks to her brother, she has

a house for her six children.

Tabu, a 28-year-old prostitute, met, talked, spent a couple hours

with in Arusha. She was going back to her village to die. She

stayed an extra day just so she could meet with us, and I will

never forget that smile, the cheerful demeanor, as we met in a

small, stick-framed hut no more than 12 by 12.

Well, these are the real faces. As we talk about the big issues,

it is that little virus. There is no cure today. There is treatment,

but there is no cure. Nine out of 10 people in the world do not even

know that they have it. As we talk about the big numbers, the big

8

programs, again we have got to remember it translates down to

those individuals that are now in the millions in Africa.

With that, Mr. Chairman, I will close and mention some of my

other things in my opening statement as we go forward. Thank

you.

[The prepared statement of Senator Frist follows:]

PREPARED STATEMENT OF SENATOR BILL FRIST

AIDS IS THE HEALTH CRISIS OF OUR TIME

Before I became a Senator, I was a heart and lung transplant surgeon. To increase the effectiveness of the surgery, I gave my patients powerful

immunosuppressant drugs—drugs that allowed the heart to survive but which made

one highly prone to infections. I was an infectious disease expert—to do the actual

transplant operation took only about 5 hours; the real challenge required never ending vigilance and action of beating back every infection so that my patients could

lead normal and fulfilling lives. That is what I did every day for hundreds of patients.

I had the honor of giving my patients, suffering from fatal diseases, a second

chance at life. But if an infection set in—an infection I could not control—my patient stopped working, he dropped out of school, he lost income to support his family, he could not be the parent he wanted to be for his children, his family became

less secure, he could not participate in his larger community, he lost hope. All normal structure to his life would dissolve. Life around him would crumble.

Now, as I sit on the Foreign Relations Committee, I see regions of the world

where the scourge of HIV and AIDS is destroying the lives of millions. Just like that

patient with fatal heart disease who can either get better with appropriate intervention or who will die, now is the critical moment to intervene to address this epidemic—the health crisis of our time.

We are all aware of the chilling state of the global AIDS pandemic. Each year,

a staggering 3 million persons die of AIDS and an additional 6 million more are

infected with HIV—mostly in poor countries. Over the next ten years, AIDS will

have claimed the lives of more people than all those, both civilian and military,

killed in World War II. Globally, nearly 37 million are infected, with 23 million

more having already died.

Particularly hard hit is the continent of Africa. In January, I traveled to East Africa and witnessed first hand the toll HIV and AIDS is taking on that continent.

Africa is losing an entire generation as 40 million children will be orphaned by

AIDS in the next decade—a number equivalent to all children living east of the Mississippi. Trained personnel—teachers, health care, military and police—are in some

countries dying faster than they can be trained. The orphans of Africa are left without parents, without teachers, without role models and without leaders making

them susceptible to recruitment by criminal organizations, revolutionary militias,

and terrorists. AIDS is destroying entire societies.

In Nairobi, Kenya, I visited the Kibera slum. With a population of over 750,000,

one out of five of those who live in Kibera are HIV/AIDS positive. As I walked the

crowded, dirty pathways sandwiched between hundreds of thousands of aluminum

shanties, I was amazed that everyone was a child, or very old. The disease had

wiped out the parents—the most productive segment of the population—teachers,

military, workers, the providers.

In Arusha, Tanzania, I met Nema whose name means ‘‘Grace.’’ She sells bananas

to survive and provide for her year-and-a-half-old son, Daniel. When Daniel cried

from hunger, Nema kissed his hand because she had nothing to give him but her

love.

Margaret, also in Arusha, whose symptoms first came on in 1990. When her husband died, despite her illness, she found the strength to fight his family to keep the

family property. Thanks to her brothers, she has a house for her six children.

And Tabu, a 28-year-old prostitute, who was leaving Arusha to return to her village to die. She stayed an extra day to meet with us, and I will never forget her

cheerful demeanor and mischievous smile as we met in her small stick-framed mud

hut, no more than 12 by 12. Her two sisters are also infected, another sister has

already died. Tabu will leave behind an eleven-year-old daughter, Adija.

These stories of a lost generation—of young mothers and their children are—

sadly—not unique to Africa.

9

Africa has suffered the most but it is not alone—India, with well over 4 million

cases, is on the edge of an explosive epidemic, which could result in 50 million cases

in the next 10 years if awareness and prevention campaigns are not rapidly implemented. The Caribbean currently has the second highest rate of infection of any region in the world—2.3% of the adult population. And Russia had the biggest increase in rate of new cases last year.

AIDS is truly a global crisis.

LEADERSHIP AND COORDINATION

The good news is we know a lot about how to reverse the epidemic. And as a first

step, it takes strong leadership at all levels, but as with most things in life, that

leadership must start at the top.

President Museveni in Uganda, with whom I spent some time on my trip, has not

been bashful about speaking very publicly to citizens of his country about HIV/

AIDS. Bakili Muluzi, President of Malawi, was in my office here in Washington just

a few days ago. He told me that he opens every speech to his countrymen with an

admonition about HIV/AIDS.

These two presidents underscore the need to bring the disease out into the light,

helping to eliminate the stigma often associated with the disease, and opening the

way for public education.

With leadership, we must also coordinate our efforts, understanding the importance of enlisting all stakeholders in the fight against HIV/AIDS. From governments, to the U.N. and the World Bank, to world leaders, corporations and philanthropies, each has an important role to play.

An effective strategy to combat HIV/AIDS must coordinate within national governments as well as across them to ensure that our resources are leveraged and put

to best use by avoiding duplication of effort. Each national sector—agriculture,

labor, finance, health, education—can contribute unique expertise and resources.

For example, the education ministry can develop programs that target the younger

generation, teaching them how to avoid risky behavior. The labor sector can resolve

difficult employment issues; the financial sector can mobilize national resources.

Each level of society has a role to play—political, ethnic, and religious leaders can

coalesce national support and reduce stigmas attached to the disease. And, as I

learned in East Africa, many of the best ideas come from those working in the

trenches to fight this disease. Local community participation is indispensable.

PREVENTION AND TREATMENT

We must fight this battle on two fronts: by improving primary prevention and expanding access to treatment.

Until science produces a vaccine, prevention through behavioral change is the key.

Even in HIV ravaged Africa, most of those who come in to be tested will test negative. This presents a real opportunity to save countless lives. I believe we should

increase investments in rapid HIV testing kits and counseling for developing countries. Access to inexpensive and rapid HIV testing can help reinforce prevention

messages and guide treatment options. And as I saw in Africa, testing centers become centers of hope for the community, a place where those struggling with HIV/

AIDS can share ideas, support each other, learn important coping strategies, and

receive medical treatment and nutritional support.

Treatment is an important part of the mix. When persons with AIDS receive medical and nutritional support, they live longer and healthier, avoiding opportunistic

infections such as tuberculosis; providing income for themselves and their families;

and ensuring a better future for their dependents. There are other potential public

health advantages to treatment that require further research and evaluation. Treatment with antiretroviral drugs lowers the amount of virus in the blood, potentially

decreasing the risk of transmission, both among adults and among mother to child

transmissions.

New treatment regimes may make an even bigger difference in extending life and

holding families together. Just as importantly, the hope of some kind of treatment

will encourage more people to have themselves tested. The more people know about

infection; the more likely they are to do something about it. Finally, support of

health care delivery systems including personnel training is essential to effective

programs.

I would like to take this opportunity to thank Secretary Thompson and Administrator Natsios and compliment them for the great work that USAID and the Centers

for Disease Control for their efforts in prevention and treatment in East Africa.

When I was in Uganda in January, I witnessed firsthand the cooperation between

USAID and the Centers for Disease Control at such centers of excellence as the

10

AIDS information center and TASO (The AIDS Support Organization) outreach program.

WHERE DO WE GO FROM HERE?

I believe we must focus our efforts around eight main goals:

• We must continue our efforts to unite the political, religious, and business leaders of the world in the international commitment to provide financial and

human resources to halt the spread of HIV/AIDS; and to help those who are

afflicted with the disease.

• We can lend support to the Global Fund for HIV/AIDS, TB and malaria in its

critical start-up phase and assist in the Fund’s efforts to meet the challenges

ahead with financial and political support. The Global Fund was envisioned as

a public/private partnership. Donations from governments to the Fund are only

part of the effort. We must also take steps to encourage corporate, non-profit,

and private donations to the Fund. For example, we could consider ways to mobilize resources for the Fund by creating tax incentives for private sector and

individual contributions. We should consider the development of dynamic methods of support for the Fund, such as non-cash contributions of pharmaceutical

and medical instrument donations to the provision of technical expertise and

staffing to public health personnel.

• Our nation’s public health community is doing great work in the fight against

HIV/AIDS. But I believe we can do still more. We should consider ways to further leverage our nation’s public health care resources and talent to address the

global HIV/AIDS challenge.

• We must continue to encourage and empower coalitions of governments, multilateral institutions, corporations, foundations, scientific institutions, and NGOs

to help fill the gap between the available resources and the unmet needs for

prevention, care and treatment. Each has unique contributions to make to the

battle. We in government should seek ways to expedite these connections

through legislation if necessary.

• We should put non-governmental and community based organizations, both religious and secular, at the forefront of action on the ground, getting funds to

them quickly so that they can most effectively do their jobs reaching out to

those who need help most.

• We must ensure that international research efforts on disease affecting poor

countries, such as AIDS, malaria and TB, are reinforced in a manner that

assures that the best scientific work in the world can lead to real benefits for

the developing world—at a cost they can afford. (CDC protocols and guidelines,

research on alternative drug schedules.)

• We must find ways to balance prevention with support, care, and treatment options that combine low cost pharmaceuticals with enhanced health care delivery

systems.

• We must take steps to provide comfort to the families and orphans affected—

to give them hope.

Our challenge is great. But as Americans, it is not in our nature to turn away

from great challenges. And I have no doubt that, as a nation, and as a people, we

will rise to it.

The CHAIRMAN. Thank you.

Today we have with us a very distinguished and important

panel, beginning with Secretary Tommy G. Thompson, the Secretary of Health and Human Services. Everyone knows of his bio.

The CHAIRMAN. He was one of the Nation’s great Governors in

my view and one heck of a Secretary of HHS. I quite frankly, for

the record, although it is all past, I appreciated your optimism during 9/11. Without you, I think there would have been a little more

panic out there. As you may recall, this is not hindsight. I said it

at the time as well. I am glad we had somebody who had been a

plain old politician in that position because of the significance of

how things would be read based on your facial and your verbal gestures. It would have made a big difference. You communicated a

11

sense of some optimism to the American people at a very important

time. So, I think your critics can go to the devil.

The CHAIRMAN. Mr. Natsios is a man well-known to us here. He

is Administrator of the U.S. Agency for International Development.

USAID is a Government agency that administers economic and humanitarian assistance worldwide and is always a whipping boy in

the past 30 years I have been here. But I think the rest of our colleagues are beginning to realize what I think we all on this committee have realized, its incredible importance and significance. I

suggest that, unless we make USAID even more robust over the

next decade or so, we will be making a gigantic mistake.

Also we have the Ambassador with us who is in a position nominated by President Bush. She was unanimously confirmed by the

Senate and sworn in as the Under Secretary of State for Global Affairs, a job that I doubt she even fully appreciated would take on

the significance it has since she has been sworn in beyond what it

already was.

So, I welcome you all. I will not take any more time.

It is very seldom that we ever do this, but I am going to recognize a man to your right, Chad Allen, because he used to be a staffer here. As long as you know you cannot speak, Chad, you are welcome. I am joking. That is a joke.

Claude. I said Chad. It is Claude. I have just been corrected,

which means I will be corrected again before this is over.

So, Claude, it is good to see you back, although as I understand

it, you are assisting the Secretary at this point, and at some point

he may yield to you. I do not know.

With that, why do we not begin. We will start with you, Mr. Secretary, and welcome any opening statement you would like to

make.

STATEMENT OF HON. TOMMY G. THOMPSON, SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC; ACCOMPANIED BY CLAUDE ALLEN, DEPUTY

SECRETARY

Secretary THOMPSON. Let me just start out by thanking you, Senator Biden, for your leadership in this area. I cannot think of a

more important hearing to take place today, and I applaud you for

your leadership in this effort and thank you so very much for having us.

The CHAIRMAN. The real leaders are the fellows on either side of

me here. But thank you.

Secretary THOMPSON. Senator Frist is one of those wonderful

outstanding leaders, and I appreciate what you do in Africa, Senator Frist. And, Senator Feingold, it is always a pleasure to be with

you and thank you for your leadership in Africa as well. It is a

great panel and I thank you so very much.

I am on the Global Fund Board and that is why I wanted to come

and testify, Senator. I am going to have to leave, but Claude Allen

is here as my Deputy, who is very interested and very much involved in this as well. He will be answering any questions that may

come after my testimony.

Mr. Chairman, thank you for your leadership in responding to

this devastating disease. And, Senator Frist and Senator Feingold,

12

thank you for all your efforts. And, Senator Frist, thank you for

your leadership on the GLIDER legislation. We may not have succeeded yet, but your efforts certainly showed leadership and your

commitment to this issue.

The administration and the Department of Health and Human

Services are fighting the war against AIDS on two fronts: here in

our own country and around the world. In all, HHS will devote $13

billion in fiscal year 2003 to fighting HIV/AIDS at all levels, an 8

percent increase over current spending.

In today’s hearing, we are discussing the global efforts, but I can

assure you and the members of the committee that our efforts

within the United States are as aggressive and focused as well.

Mr. Chairman, as you know, Secretary of State Colin Powell and

I serve as the co-chairs of the Task Force on HIV/AIDS, which was

created by President Bush. We all know too well the dreadful, terrible statistics: 40 million individuals around the world living with

HIV//AIDS and 3 million deaths from AIDS last year alone.

The scourge of AIDS threatens to destroy economies and social

systems, to promote national instability and civil unrest, and to

draw the United States and other developed nations into national

and regional conflicts.

The administration is aggressively responding on numerous

fronts, gathering resources from all across the Federal Government

to battle HIV/AIDS and other infectious diseases.

Within my Department of Health and Human Services, the Centers for Disease Control and Prevention, the Health Resources and

Services Administration (HRSA), and the NIH are world leaders in

research and assistance. In addition, we are closely cooperating

with private groups, the religious and non-sectarian charities that

do so much good work internationally.

President Bush took the bold step last May 11th of announcing

the first national contribution to the Global Fund to Fight HIV/

AIDS, Tuberculosis, and Malaria. I am keenly aware of this committee’s support for this effort and thank you and applaud you for

it.

Organization of the fund has moved forward with remarkable

speed since then. I am pleased to report to you, Mr. Chairman, that

the fund now totals almost $2 billion in resources pledged by public

and private sources.

The Global Fund held its first board meeting January 28 and 29

in Geneva. It was a great pleasure for me to be able to announce

the President’s pledge to the fund of an additional $200 million in

fiscal year 2003. This latest contribution brings the total U.S. contribution to a half a billion dollars, by far the largest donation from

any one country or entity, representing more then one-quarter of

the overall commitments to the fund.

I can also report that a consensus has formed within the board

that coincides with the President’s priorities and the principles for

the fund’s operation. Let me, please, quickly highlight them.

First, the President spoke of the need for partnerships across

borders and among both the public and private sectors. Accordingly, the fund is an independent, nonprofit foundation under

Swiss law, located in Geneva in space separate from the United

Nations.

13

Its board consists of seven donor governments, seven developing

country governments, one representative from the philanthropic

sector, one representative from the for-profit sector, and two representatives from nongovernmental organizations.

The second issue. The President called for an integrated approach to the three diseases, HIV/AIDS, malaria, and tuberculosis,

emphasizing prevention and training of medical personnel, as well

as treatment and care, including the use of new medicines. We are

very pleased to be able to report to you today the rest of our colleagues on the fund’s board are in agreement with these principles.

The third principle. The President called for financial accountability. To that end, the board has agreed to put in place strong

financial and programmatic accountability mechanisms. The World

Bank is going to serve as the fund’s trustee and have the responsibility for the financial accountability.

All partnerships that receive grants will be subject to independent audits and provide assurances of adequate fiscal controls.

Grantees must be able to demonstrate that their approaches are

having a real impact in reducing mortality and illness.

Fourth principle. The President wanted scientific accountability.

A plague of this magnitude demands results. So, medical and public health experts must review all proposals for their effectiveness.

A 17-member independent technical review panel, composed of

six experts in HIV/AIDS, three in malaria, three in TB, and five

from other disciplines, will evaluate all the proposals for soundness, feasibility, and financial management.

Finally, the President underlined the importance of innovation in

creating lifesaving medicines that will combat this horrendous disease. We believe the fund must respect intellectual property rights

as an incentive for vital research and development.

The fund, gentlemen and members of this committee, is on track

and open for business. Contracts with the World Bank and the

World Health Organization for financial and administrative services should be finalized within the next couple weeks. We are also

currently looking for an executive director.

Applications are currently being taken for the first round of partnership grants. The board plans to make decisions on applications

when it meets again in New York City the end of April.

In short, the President, Secretary Powell, and myself are delighted that the fund has surpassed even our most ambitious expectations, and we remain convinced that innovative approaches

like the fund are truly our best hope for curbing this terrible disease in the developing world.

Of course, there is another important work that is being performed each and every day, contributing greatly to the plight

against the scourge of HIV/AIDS. My Department is on the ground

currently in 18 countries and will be in 25 by the end of the year,

working intensely with governments, NGO’s, and community

groups to build infrastructure, assist in prevention, and provide direct care and treatment.

Certainly we concentrate on Africa where the disease is most

widespread and at its deadliest. But I am also very concerned

about the Caribbean Basin, which is the second real troubling spot.

This April I will be meeting in Guyana with Caribbean health minVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00017 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
14

isters to assess the regional status of the disease and develop new

ideas for addressing HIV/AIDS.

The President’s fiscal year 2003 budget calls for $144 million for

the HHS global AIDS program, separate from the Global Fund, the

same funding level as the current year. In addition, the budget includes $11 million for international

HIV prevention research at the Centers for Disease Control and

Prevention in Atlanta.

At HHS, we do provide funding and technical assistance to ministries of health to bolster disease surveillance and essential laboratory services, including training for laboratory personnel and

purchasing needed equipment. We also offer technical assistance

and funding for a variety of prevention activities, including voluntary counseling and testing, preventing, which I think is so important, especially in Africa, mother-to-child transmission, blood

safety, and sexually transmitted disease prevention. Even our

treatment and care activities, like technical assistance on

antiretroviral therapies, or ARV’s, are proving to be vital pathways

to prevention activities.

The team at HHS is assessing ways to be more effective, to safely

and affordably bring these treatments to desperate countries and

their people.

Finally, I would be remiss if I did not mention this country’s

commitment to research and practical assistance to battle HIV/

AIDS. President Bush’s budget and proposed funding for fiscal year 2003 for NIH includes $2.77 billion for AIDS-related research and

an increase of $225 million specifically for vaccine, microbicide, and

treatment research. Next year we will devote more than $420 million to the search for an HIV vaccine, a 24 percent increase over

fiscal year 2002. Of course, the benefits of research into a cure for

HIV know no boundaries.

Mr. Chairman, members of the committee, we have a compelling

moral interest in helping poor nations fight a disease that is literally killing millions of their citizens. Through the Global Fund

and our continued dedicated efforts at HHS and its agencies, we

can offer real and effective help to those in need.

I thank you again, all of you, for your support, your passion on

this very important endeavor. I am sorry I must depart, but Deputy Secretary Claude Allen will be here to answer any and all

questions you may have.

[The prepared statement of Secretary Thompson follows:]

PREPARED STATEMENT OF HON. TOMMY G. THOMPSON, SECRETARY, DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Mr. Chairman, members of the Foreign Relations Committee, I am pleased to be

here today to provide an overview of the activities of the Department of Health and

Human Services (HHS) to combat HIV/AIDS worldwide.

Thank you, Mr. Chairman, for you leadership in responding to this devastating

disease. I want to acknowledge Senators Frist and Kerry for their work as co-chairs

of an important task force organized by the Center for Strategic and International

Studies (CSIS) on America’s role in addressing the global HIV/AIDS pandemic. We

at HHS, along with the U.S. Agency for International Development and the U.S. Department of State, are working with CSIS to ensure that this two-year project reaps

benefits for both the U.S. and nations around the world hard-hit by HIV/AIDS.

We all know the dreadful statistics—40 million people worldwide now living with

HIV/AIDS, 3 million deaths from AIDS last year—but they don’t begin to represent

the devastation this disease wreaks upon the developing world. The relentless onVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
15

slaught of AIDS has the potential to devastate national economies and social systems, cause national instability and civil unrest, and thaw the United States and

other developed nations into national and regional conflicts. This Country has a

moral obligation to provide leadership in mobilizing resources for this international

health crisis.

Secretary of State Colin Powell and I serve as co-chairs of the Task Force on HIV/

AIDS created by President Bush, and, under his leadership, the United States has

continued its commitment to battle HIV/AIDS and other infectious diseases and assist the world in disease control, surveillance and treatment activities. At HHS, the

Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the National Institutes for Health (NIH) are world

leaders in research and assistance in the worldwide battle against this scourge.

Last May 11, President Bush announced the creation of the Global Fund to Fight

HIV/AIDS, Tuberculosis and Malaria. I have the honor of serving as the U.S. representative to the Global Fund Board, a post I sought because I believe the Fund

can make a real difference. Both Secretary Powell and I have championed the concept of a trust fund for these three diseases from our first days in office. And, I

might add, so have many of you on this committee supported this effort. Thank you,

Senator Frist, for your contributions in this area. Why is this idea so important?

Because Africa and other parts of the world urgently need a public health delivery

system that includes prevention of new infections; treatment for the sick, including

the provision of drugs; and training of medical professionals.

The speed with which the Fund’s architecture has been established is remarkable,

and President Bush’s founding pledge of $200 million has produced a 10-fold return

on that investment in 9 months. I am pleased to report to you, Mr. Chairman, that

the Fund is now up to just below $2 billion in promised resources.

The Global Fund held its first Board meeting on January 28 and 29, 2002, in Geneva. Because President Bush asked me to stay in Washington to meet with Ministers from the newly formed provisional government of Afghanistan, I was unable

to attend. I did, however, address my fellow Board members by videoconference to

announce the President’s pledge to the Fund of an additional $200 million in FY

2003. This latest proposed contribution would bring the total U.S. contribution to

half a billion dollars, by far the largest donation from any one country or entity,

and over one-quarter of the overall commitments to the Fund.

The establishment of the Fund reflects the principles and priorities President

Bush outlined last May. First, the President spoke of the need for partnerships

across borders and among both the public and private sectors. The Fund embodies

this principle; it is an independent non-profit foundation under Swiss law, located

in Geneva in space separate from the United Nations and any of its agencies. The

Board of the Fund consists of 7 donor governments, 7 developing country governments, 1 representative from the philanthropic sector, 1 representative from the forprofit sector, and 2 representatives from non-governmental organizations (NGOs).

Second, the President wanted the Fund to pursue an integrated approach to the

three diseases that emphasizes prevention, training of medical personnel, as well as

treatment and care. We are pleased that the rest of our colleagues on the Fund

Board have agreed that proposals may cover prevention, treatment, and care and

support in dealing with the three diseases in ways that local partnerships deem appropriate.

The Board has decided not to institute quotas or percentages for particular interventions. Prevention is indispensable to any strategy of controlling a pandemic such

as we now face, but so are treatment activities, including carefully designed programs employing antiretroviral therapies.

Third, the Fund should concentrate on programs that work. We must know that

the money is well spent, people living with HIV/AIDS are well cared for, and local

populations are well served. To that end, the Fund Board has agreed that strong

financial and programmatic accountability mechanisms must be put in place. The

World Bank will serve as the trustee for the Fund, and have the responsibility for

financial accountability, including collection, investment and management of funds,

disbursement of funds to countries and programs, and financial reporting to stakeholders. All partnerships that receive grants will be subject to independent audits

and provide assurances that adequate fiscal controls are in place. While the Board

has not yet decided exactly how ongoing monitoring and post facto evaluation of

grants will be done, the Board has embraced the principle that funding must be tied

to measurable results. Grantees must be able to demonstrate that their approaches

are having a real impact in reducing mortality and illness.

The President’s fourth criterion asks for scientific accountability. All proposals

must be reviewed for effectiveness by medical and public health experts, because a

plague of this magnitude demands results. The Board will have ultimate decisionVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
16

making authority and be accountable for results, but no proposal will move forward

without a rigorous review and endorsement by a group of technical experts. This

17-member, independent Technical Review Panel, composed of 6 experts in HIV/

AIDS, 3 in malaria, 3 in TB, and 5 from other disciplines, will evaluate all proposals

for programmatic and medical soundness, feasibility, and financial management,

taking into account local realities and priorities. Indeed, my Department hosted a

meeting of eminent experts from around the world last month, at the NIH’s Fogarty

International Center, to develop recommendations to the Fund Board on the operating procedures of the Technical Review Panel—advice the Board has accepted.

And, finally, the President underlined the importance of innovation in creating

lifesaving medicines that combat diseases. Our position has been that the fund must

respect intellectual property rights, as an incentive for vital research and development.

I will not hesitate to admit that much work remains to be done, but the Fund

is on track and open for business. Contracts with the World Bank and the World

Health Organization for financial and administrative services should be finalized in

the near future. We are also looking for an Executive Director. Proposals for grants

need to be written; in fact, applications are currently being taken for the first round

of partnership grants. The Board plans to make decisions on applications during its

next meeting in April.

So, as I have mentioned, the Fund is open for business and we at HHS intend

to participate actively in helping partnerships to design their proposals and perhaps

even join in monitoring and evaluation if asked. I see the Fund as a critical opportunity to force better coordination between bilateral and multilateral programs and

to hone their focus on results and performance.

The President, Secretary Powell and I are all delighted that the Fund has surpassed even our most ambitious expectations, and we remain convinced that innovative approaches like the Fund are truly our best hope for curbing these diseases in

the developing world.

HHS PROGRAMS IN THE GLOBAL HIV/AIDS ARENA

My Department’s contributions in this arena also include the efforts of the CDC,

HRSA, and NIH. Let me briefly share with you the very important work that these

agencies are performing. The President’s Fiscal Year 2003 budget calls for $144 million for the HHS Global AIDS Program within the Centers for Disease Control and

Prevention, the same funding level as this year. In addition, the CDC budget includes $11 million for international HIV prevention research.

The Department is on the ground in 25 countries in sub-Saharan Africa, South

and Southeast Asia, Latin America, and the Caribbean, working intensively with

governments, NGOs and community groups to build infrastructure and capacity, assist in prevention activities, and provide direct care and treatment.

Most developing nations lack the necessary infrastructure to address their HIV/

AIDS epidemics. Disease surveillance systems and epidemiology are often nonexistent or greatly compromised, making it difficult if not impossible to accurately

determine at-risk and infected populations.

HHS provides funding and technical assistance to Ministries of Health to bolster

disease surveillance and essential laboratory services, including training for laboratory personnel, information systems program monitoring and evaluation, and purchasing needed equipment.

We also offer technical assistance and funding for a variety of prevention activities, including voluntary counseling and testing, preventing mother-to-child transmission, blood safety, sexually transmitted disease prevention and care, behavior

change communications, and prevention for populations at high risk for acquiring

or transmitting HIV.

For example, preventing mother-to-child transmission is a priority for our programs—it is the only proven therapy to avert transmission from one person to another. HHS works with host countries and other partners to provide drug therapy

to pregnant and post-partum women and their newborns and promotes replacement

feeding strategies to avoid transmission via breast milk.

Our treatment and care activities focus on tuberculosis and other opportunistic infections, palliative care, and, more recently, technical assistance on antiretroviral

therapies, or ARVs. Within HHS, the HRSA and CDC are training local health care

providers in safe and effective patient care and monitoring. Working together, our

agencies are fostering hospital- and clinic-based care programs, as well as

community- and home-based care, for people living with HIV/AIDS.

Let me say a few words about ARV treatment, a subject that has drawn intense

interest here and around the world. ARV treatment is now more affordable in subVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
17

Saharan Africa than ever, thanks to the assistance of drug manufacturers in this

country and others. While most developing countries lack the sophisticated medical

monitoring equipment and tests that are adjunct to ARV treatment, my team at

HHS is assessing ways to effectively, safely and affordably bring these treatments

to desperate countries and their people. CDC and HRSA are also examining the

safety and effectiveness of what is known as ‘‘syndrome management,’’ which means

that diagnosis and continuing care are based on observable signs and symptoms,

rather than sophisticated lab tests. These tests are not feasible in most countries

in which the Fund will be working, so in such situations, clinicians there have to

manage patient care by look and touch and feel—all skills that can be taught, and

we hope that this effort will be another part of our contribution to the Fund.

Tuberculosis presents special dangers to those who are HIV-infected, and HHS

currently is assessing a rapid TB diagnostic test that is effective among HIV-positive persons; the optimal duration of TB treatment among those who are HIV infected; and the acceptability of directly observed antiretroviral therapy for HIV.

With the Botswana Ministry of Health, HHS research showed that TB is the leading

cause of death for HIV-positive persons in Botswana and another showed that saliva

tests for HIV can be used on TB sputum specimens, offering an effective tool for

HIV surveillance.

Finally, the importance of research in attacking HIV/AIDS has long been recognized, and the United States has long been the world’s leader in research and practical assistance to battle HIV/AIDS. President Bush’s proposed FY 2003 funding for

the National Institutes of Health includes $2.77 billion for AIDS-related research,

an increase of $255 million that includes expansions for vaccine, microbicide, and

treatment research. Next year, we will devote more than $422 million to the search

for an HIV vaccine, a 24 percent increase over FY 2002.

Last year, the NIH Office of AIDS Research developed the Global AIDS Research

Initiative and Strategic Plan which reaffirmed NIH’s long-standing commitment to

international HIV/AIDS research. NIH supports a growing portfolio of HIV/ATDS

research conducted in collaboration with investigators in developing countries, and

supports international training programs and initiatives to help build research. Altogether, NIH expects to spend $222 million in FY 2003, an increase of $34 million

over FY 2002, specifically related to international HIV/AIDS research.

The NIH supports the HIV Vaccine Trials Network (HVTN), composed of 16 domestic and 13 international sites. Directly and through collaborations with mostly

university-based investigators worldwide, the HVTN also supports laboratory research to ensure vaccines are efficacious against a variety of HIV strains found

around the world.

HHS also supports university-based biomedical and behavioral research on interventions to prevent sexual transmission, and strategies to reduce perinatal transmission. The NIH-sponsored HIV Prevention Trials Network (HPTN) is a worldwide

collaborative network designed to conduct research in 16 international and nine domestic sites on promising and innovative biomedical/behavioral strategies for the

prevention or reduction of HIV transmission among at-risk adult and infant populations.

HHS works to strengthen—or create—the research and laboratory infrastructure

of developing countries and train local investigators to conduct clinical trials of

therapeutic and preventive therapies. These efforts include NIH’s Fogarty International Center, which funds training in the U.S. for scientists from developing

countries in Africa, Asia, Latin America and the Caribbean. Through grants to U.S.-

based institutions, we have also conducted training courses in 60 countries. A new

initiative, the Comprehensive International Program of Research on AIDS, also provides funding directly to foreign institutions for HIV research that is relevant to the

host country. These grants focus on training of investigators and enhancement of

laboratory and clinical capabilities, and to date, we have made five such awards.

None of the activities I’ve just outlined—infrastructure development and capacity

building, prevention activities, care and treatment efforts, and research—could be

accomplished or even attempted without the integral cooperation and collaboration

between CDC, HRSA and NIH, as well as other parts of the U.S. government, most

particularly USAID. At HHS, I am working to ensure that research and activities

conducted throughout the Department, as well as within other entities, is complementary and not duplicative, and that it sees practical application in programs.

HHS has a 20-year history of international intervention research, established CDC

field stations, and many NIH projects worldwide. We strive to keep these efforts coordinated, and with the help of our other government partners, I believe we are succeeding.

18

CONCLUSION

Enormous challenges lie ahead. Just last month, the president of Family Health

International, one of our NGOs, asserted that without treatment and prevention,

AIDS will outstrip the bubonic plague as the world’s worst pandemic. Bubonic

plague killed 40 million people in the 14th century. Seven centuries later, we stand

at the brink of an even worse catastrophe. But working together, we can change the

course of the AIDS epidemic. Our research and its practical application have shown

us that prevention, care, and treatment work. It is our responsibility to ensure that

those at risk and those already infected have the benefits of that knowledge.

We are seldom presented with such clear and pressing need and such clear means

to intervene. The Administration stands ready to contribute to a comprehensive

plan for Africa and other parts of the world where HIV/AIDS is rapidly expanding.

I thank you again for your support of this important endeavor.

The CHAIRMAN. Mr. Secretary, before you depart, if we each can

ask you one brief question. Then we will ask Claude a number of

questions.

Congress appropriated $300 million in fiscal year 2002 for the

Global Fund for AIDS, Tuberculosis and Malaria. The President’s

budget for 2003 requests only $200 million. Are you concerned that,

by requesting less than what was appropriated last year, we are

sending a negative signal to the international community?

Secretary THOMPSON. No, I am not because at the time that we

said we were going to set up this fund and the President announced it, he indicated it was only going to be a 1-year contribution. The second year Colin Powell and myself requested of the

President that there should be some additional money put into it.

The President agreed. $200 million under the circumstances that

we are facing right now I think is a tremendous, generous contribution.

The fund board, I want to be able to report to you, Senator, was

ecstatic when I was able to announce that we were going to have

an additional contribution this year of $200 million. It certainly

would be nice if we had $300 million, but the $200 million was certainly well received by the board and by the countries represented

at the meeting in Geneva.

The CHAIRMAN. The Congress may help you along again this

year.

Secretary THOMPSON. Thank you, Senator. We certainly would

not turn it down, Senator.

The CHAIRMAN. Do you have a question?

Senator FRIST. Thank you, Mr. Chairman.

Mr. Secretary, an issue that would probably be useful for you to

comment on before you leave is this idea of coordination, and we

will hear a little bit more about that later. But as you read through

the materials both provided to us and where a lot of the discussion

is, we have the funding issues, we have this whole linkage between

prevention, care, and treatment, which is important to me, but

then also internally how things are going to best be coordinated

with this administration. We can compare it to the previous administration, which will be done. But I guess the real concern is how

can we best coordinate who we are going to hear from today as well

as tomorrow in a way that really does most effectively use the inputs. Everybody will be looking at the dollar figure as a measure

of input, but it is much more complex than that.

19

We know we have the group at the cabinet level between you and

the Secretary of State and others. Could you give us some sort of

feel—again, we will explore it in more detail in later questioning—

of both your commitment, but also to the potential for success of

the current organization as both proposed and as carried out in the

last several months?

Secretary THOMPSON. I think the coordination is exceptional.

This is an issue that both Colin Powell and myself are passionate

about. We have got other members of the cabinet very much involved in this. Our staffs meet regularly, almost weekly on the

fund. In setting up the fund, they have been meeting more than

weekly. The Secretary of State was represented at the fund, as I

was, and we will continue to do that kind of cooperation and coordination.

We are also setting up this task force of 17 members which is

going to review scientifically the grants, and we are going to have

a lot of input from NIH and CDC to make sure that that is done

correctly and properly. This is the ongoing thing. I can assure you

that the cooperation and the coordination between State and the

Department of Health and Human Services are at the utmost and

we will continue to do so in the future.

Senator FRIST. Again, I know you need to leave.

The issues of the Department of Defense and Labor—clearly, we

need to get all of these efforts together with a real focus. I guess

what I am searching for is some reassurance that beneath the

President of the United States at the highest level, we have people

addressing it with the idea of coordinating all of it. Obviously, what

State is doing and HHS is the prominent role, but is the structure

there to take all the resources beyond the Global Fund itself?

Secretary THOMPSON. Absolutely, Senator. The Department of

Defense is very much involved in it with their staff people with our

staff people, and they meet with us. This cooperation continues and

will continue. I can assure you.

Senator FEINGOLD. Thank you, Mr. Chairman. It is good to see

my friend here. I know you have to get going. You and I have made

an art in Wisconsin out of usually agreeing and then disagreeing

agreeably when we need to.

Secretary THOMPSON. Minimally on the last one, Senator.

Senator FEINGOLD. Usually agreeable.

Of course, I admire all you have done here and in Wisconsin.

Let me just say, as I said to Secretary Powell last week. I am

afraid I do not see the $200 million as an adequate contribution in

light of what Kofi Annan has called for. I know you are very sincere in your desire to get after this problem. I know that having

watched you go after health care issues in Wisconsin. But let me

just say that for the record, that I just do not think it does the job

and it does not reflect the leadership role that our country has to

take.

But let me just ask you a different kind of question. What kinds

of positive spill-over effects that are not directly related to HIV/

AIDS but perhaps encouraging or encompassing other health and

development issues are gained when in places around the world we

have a robust U.S. effort to help fight AIDS?

20

Secretary THOMPSON. I think so much, and the Caribbean Basin

is an absolute prime example of that. The Caribbean nations are

coming together recognizing that they have a serious problem with

HIV/AIDS, and the fact that the fund is set up, they are going to

be very much involved in it. They have asked me to come down and

meet with their health ministers to see how they could play a larger role in being able to stem the threat of AIDS and the growth

of AIDS. That is just a prime example of what this Global Fund

has been able to set up, is more people interested.

You are going to find the same in China, India, and Pakistan

where the next, probably, threats are going to be for HIV/AIDS,

and Russia. All of these countries now are taking a look at Africa

and saying we have got to make sure that that does not occur in

our country. I am much more cognizant of that, and the AIDS fund,

the Global Fund, is going to allow for the dollars, hopefully not

only to be in Africa, but these other countries to take a leadership

role.

Senator FEINGOLD. Thank you, Mr. Secretary.

The CHAIRMAN. Thank you, Mr. Secretary, for being here.

Secretary THOMPSON. Thank you, Senator.

The CHAIRMAN. Mr. Natsios, thank you for your patience.

STATEMENT OF HON. ANDREW NATSIOS, ADMINISTRATOR,

U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT, WASHINGTON, DC

Mr. NATSIOS. Thank you, Chairman Biden, members of the committee, Dr. Frist, and Senator Feingold. Thank you for leadership

on this issue.

I will make some brief remarks and ask that the full version of

my remarks be included in the record, if I could.

We are all familiar with the grim statistics that drive our policy

and our programs in this terrible epidemic. An estimated 40 million are now living with HIV/AIDS. Another 40 million are expected to become infected in just the next 8 years unless we act.

Economic and social and human costs of the pandemic are almost

beyond reckoning.

One of the first actions I took as Administrator, when I was confirmed by the Senate in May of last year, was to send a cable out

to our missions to tell them that they needed to integrate not just

in the health sector our program in HIV/AIDS in our 75 field missions but across all sectors.

We know, for example, in Zambia that more teachers are dying

of AIDS than are being graduated from the teachers colleges.

We are challenged in agriculture, for example. There are villages

in Uganda where there are no adults alive who are capable of

farming. So, there are only children and elderly people left. Everyone else has died. So, you are seeing malnutrition rates that are

famine level in some areas not because there is a drought or a war

or a pestilence attacking the crops or there is a problem of the

farmers. The problem is the farmers have died and there is no one

to grow the crops.

So, we have integrated into our programs in a number of countries that are particularly hard hit a food aid component to support

the AIDS orphans and elderly people who do not have breadVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
21

winners capable of supporting them anymore. We are doing this in

conjunction with the ministries of health and the ministries of agriculture.

There is nothing more important to the U.S. Agency for International Development and to me personally than dealing with the

HIV/AIDS pandemic. For the last 15 years, we have led the effort

in AID to fight this dreaded disease. Based on our experience in

more than 50 countries, we have devised a six-part strategy to combat the pandemic, and I would like to just go through those six

points.

The first is prevention. This has been the cornerstone of our policy since 1986. The single most important element in preventing

the spread of HIV/AIDS is changing people’s behavior. This is

whether you are in the north or the south, whether you are in the

United States or whether you are in eastern Europe or Africa, especially among 15- to 24-year-olds. Young people are often difficult

to reach and we have had success in crafting messages that they

embrace and that will change their behavior.

In Zambia, for example, our work helped delay the age of sexual

debut by 2 years, and as a result, the prevalence rates in this age

group have now dropped by 50 percent in that country. The same

thing has happened in Uganda.

Our programs stress abstinence and faithfulness, working

through our faith-based and community-based partners. We have

seen in Uganda how effective partnerships can be between political

and religious leaders, and we have given them our strong support.

When I traveled with Colin Powell last May on his first trip to

Africa, I asked in each country to meet with religious leaders from

all denominations. I had an interesting conversation with the deputy head of the Islamic Doctors Association of Uganda, two Catholic bishops, an Anglican bishop, and a Pentecostal pastor who explained to us what they were doing in their parishes and in their

mosques to combat the epidemic. It is very interesting. Since that

lunch we had, they had not been actually talking to each other in

an organized, aggressive way, and the fact that they had very similar problems and very similar approaches to this led to a successive

set of meetings that now are integrating the religious community

in Uganda.

The second strategy that we are focusing on beyond prevention

is treatment, care, and support. While there is no cure yet, we can

help people survive longer by treating opportunistic infections like

tuberculosis and helping countries build up their health care systems. As the cost of antiretrovirals declines—and there has been a

dramatic drop in the last year in these costs—our funding increases, we are now considering incorporating ARV’s into our care

and treatment program. Accordingly, we are now finalizing arrangements for four sites in sub-Saharan Africa where the health

infrastructure permits their use, and we hope within the next few

weeks we will be announcing agreements with the ministries of

health in those four countries to begin the new antiretroviral therapies.

The third part of our strategy involves the millions of children

who have lost parents to HIV/AIDS. I have been to Africa dozens

and dozens of times over the last 13 years and I have seen the

22

faces of these children. When I was with an NGO, World Vision,

we cared for 6,000 AIDS orphans in Uganda with a World Bank

loan that was organized through the Ugandan Government. Of

course, Uganda was one of the hardest hit earliest. The Ugandan

Government has been very aggressive in combating the epidemic.

But there are many things that need to be done in upbringing of

children who are AIDS orphans.

We now have 60 projects in 22 countries that provide children

with food, shelter, clothes, school fees, counseling, psychological

support, and community care.

The fourth element of our strategy involves surveillance and

monitoring. We are always learning new things about HIV/AIDS.

There are now at least 15 different subtypes of the virus. One of

our programs funds the Centers for Disease Control and Prevention

research to understand better the dynamics of transmission.

Through the Census Bureau, we have been tracking HIV/AIDS

data for years. Our figures are the standard now that are used in

the international community. Nevertheless, we must keep monitoring the disease so we can track our programs and improve our

strategies.

The fifth component is encouraging governments and multilateral institutions to increase their financial commitments to fight

the pandemic. The United States now provides one-third of the

total world’s resources to fight the HIV/AIDS pandemic, four times

what the next largest donor gives. We supply one-fourth of the

UNAIDS fund and one-third of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. I might add that USAID has staffed with

our staff, that we secunded the initial executive secretariat of the

trust fund to work out the technical details of managing this. In

addition, we have contributed $1 million toward the management

of the fund.

Finally, there is no substitute for leadership. Whether the issue

is HIV/AIDS, democracy, or building free markets and institutions,

the most important factor in development is the quality of national

leaders and their commitment to their people’s well-being. So, the

sixth part of our strategy is to encourage and support national

leaders to become strong advocates for programs that educate people about the disease and what they must do to prevent its spread.

I have met with at least a dozen presidents and heads of states in

Africa, in particular, but also now in other areas of the world, Central America for example, who are now leading the fight in their

countries.

I would commend in particular the President of Tanzania. President Museveni was the first African leader in Uganda to lead the

fight. The President of Senegal, the President of Mali has been a

leader. The President of Mozambique, and Dr. Mocumbi, who is the

Prime Minister of Mozambique, a friend of mine, is a medical doctor, and he has been leading the charge in Mozambique against the

spread of the disease. I just met Friday with the President of Malawi who has also becoming very aggressive and very public in his

champion of the effort to defeat the disease.

USAID was the first U.S. agency to fund international HIV/AIDS

programs. Our program budget grew each year until the early

1990’s and then leveled out for several years. It is now growing sigVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
23

nificantly again and will reach $435 million this fiscal year for bilateral programs. This does not include the $100 million that we

are giving next fiscal year for HIV/AIDS or the $50 million we gave

in the current fiscal year. By the end of this fiscal year, we will have spent in AID $2 billion on HIV/AIDS prevention and care.

For fiscal year 2003, I am proud that President Bush has re- quested $540 million for HIV/AIDS programs within the bilateral

program of AID, a five-fold increase since 1999.

Secretary Powell has placed this crisis at the top of our foreign

policy agenda in the developing world and has been one of the leaders worldwide in focusing the world’s attention on this terrible disease.

Thanks to the White House and the leadership of the Congress,

we have resources now to begin making a difference on a global

scale. Much of the period during the 1990s, Mr. Chairman, we experimented with various programs. Some of the programs were successful in driving the infection rate, some were not. What we are

now capable of doing, because of the level of resources we have

been giving, is to scale up these pilot programs to a national level.

We know that they work. After you try them in three countries and

they have the same result in all three countries, you know that if

you extend it worldwide in the developing world, it will be successful.

We have been working carefully with the ministries of health,

and there is now a consensus in the developing world among the

ministers of health that we work with on a daily/weekly basis with

our health offices and our mission directors, what works, what does

not work, where we need to focus our attention.

One of our most important management tools is to get more impact from every dollar we spend. This means spending more money

in the field and cutting back here in Washington. Funding for

country programs, therefore, will grow from $192 million to $398

million in our next budget, increasing the percentage we spend in

the field from 61 percent to 78 percent. So, not only will we have

more money for prevention, care, and treatment and children’s programs, but more of it will be spent where it is needed the most.

We are increasing our HIV/AIDS priority countries from 17 to 23,

adding substantially to what we spend in each of them. We have

listened carefully to what Congress has told us. Sub-Saharan Africa continues to be our highest priority. Our new plan significantly

increases funding for this region.

We are also focusing more strategically on hot spots where the

epidemic is expanding and creating a central Condom Fund to consolidate our acquisitions, save money, and double what we purchase in terms of the volume of condoms in this next year.

Before closing, I would like to thank the committee for approving

the nomination of our new Assistant Administrator for the Bureau

of Global Health, a new bureau that I created to focus attention of

our program on the health issue. The person that the President

nominated who is now in place, Dr. Anne Peterson, is a medical

doctor herself. She spent 6 years in Africa working on HIV/AIDS

programs in Kenya and Zimbabwe and on other health problems.

So, we now have a professional who has been confirmed by the

24

Senate who is in charge of our health programs worldwide. We are

fortunate to have her.

We are in a race against time, Mr. Chairman, with a virus that

shows no signs of letting up. The war on AIDS will be a long and

arduous one, but it will be one that we ultimately will win. Thank

you.

[The prepared statement of Mr. Natsios follows:]

PREPARED STATEMENT OF HON. ANDREW S. NATSIOS, ADMINISTRATOR, U.S. AGENCY

FOR INTERNATIONAL DEVELOPMENT [USAID]

Chairman Biden, members of the Committee, thank you for inviting me to speak

today on this topic of singular importance.

I would like to begin by thanking this Committee for supporting our efforts to address HIV/AIDS. Your cooperation and your understanding of the magnitude and

complexity of the pandemic has helped USAID maintain its leadership in the fight

against this terrible disease. There are many aspects to the disease, the consequences of which are felt every day by millions of people throughout the world.

We look forward to working with you closely as you draft a new authorization bill

for HIV/AIDS this year. The U.S. Agency for International Development has a budget of $8.7 billion this

fiscal year and programs in more than a hundred countries, but there is nothing

more important to our agency—and to me personally—than dealing with HIV/AIDS.

Time is not on our side. Since becoming USAID Administrator, I have made it

a priority to streamline our procedures, so that more of our program money goes

directly to the field and it gets there faster. We are also increasing the number of

priority countries we focus our resources on, strengthening our regional programs

and taking steps to improve our accountability.

You all know the grim statistics that drive our policy. Twenty-two million people

have already died of HIV/AIDS. Ten percent of that number 2.3 million people—died

last year in sub-Saharan Africa alone. Thirteen million African children have already lost a parent to the disease, and we expect that figure to triple by the end

of this decade. The cost—to individual citizens, to families, communities, and countries—is almost beyond reckoning.

An estimated 40 million people are living with HIV/AIDS today. Far too many of

them will die unless a cure is found—and none is yet in sight. Ninety-five percent

of those who are infected live in the developing world. A third of them are between

the ages of 15 and 24. Many do not even know they are infected or what to do if

they are. Every six seconds another person gets the virus. By the end of this decade,

another 40 million people may become infected.

Ten years ago no one anticipated the speed at which the pandemic would grow

or the way it would spread through different sectors of society. HIV infection has

reached alarming levels in southern Africa. One-third of the adults in Botswana, Lesotho, Swaziland and Zimbabwe are living with it now. In South Africa, one adult

in five is infected. For many years, prevalence rates in West Africa were lower than

elsewhere on the continent, but now we are seeing worrisome increases in infection

rates in countries like Nigeria and Cameroon.

It is not just sub-Saharan Africa that is affected. Infection rates in some parts

of the Caribbean are now the second-highest in the world. In Haiti and the Dominican Republic, for example, HIV testing suggests that more than one adult in 12 is

living with the virus.

It is not just the millions who are infected today, but the speed at which the infection rate is growing that makes it so threatening. In Russia and the republics of

the former Soviet Union, the rate of increase in HIV/AIDS cases is the highest in

the world. In Russia alone, the number of officially recorded cases rose from just

under eleven thousand in 1998 to 147,000 by late last year, and some suspect the

numbers could be considerably higher.

In Asia, where prevalence has generally been low, there are signs of troubling

change. India now has some four million people with the virus. In Indonesia, where

HIV among prostitutes was once virtually non-existent, the infection rate among

this group is now as high as 26%. Prevalence has risen very quickly among these

same groups in Vietnam: in Ho Chi Minh City, over 30 percent of them are now

HIV positive. Prevalence among injecting drug users is over 50 percent in some Vietnamese cities.

Apart from the individual human costs, the economic, political and social consequences of these facts are staggering. Clearly, HIV/AIDS is not just a health probVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
25

lem. In some parts of the world the pandemic is threatening the very fabric of society. There are places in Malawi, Uganda, Zambia, and Zimbabwe, for example,

where HIV/AIDS has taken such a toll on farmers and farm workers that we are

seeing alarming rates of malnutrition, even near famine-like conditions where food

supply should be abundant and the people healthy.

It is no secret either, that population is declining in some countries, in part because women are dying before they live long enough to bear children. By the end

of this decade, average life expectancy in the countries hardest hit by HIV/AIDS

could be less than 40 years—comparable to what it was one hundred years ago.

Studies in Cameroon, Kenya, Swaziland, Tanzania, Zambia, and other sub-Saharan countries suggest that gross domestic product could be reduced by as much as

25 percent over a 20-year period. Some African companies have estimated the cost

of HIV/AIDS in terms of health care, sick days and training new hires is reducing

their productivity by 5 percent annually, and profits by 6 to 8 percent.

AIDS is like few other diseases, in that it strikes young adults most frequently.

Young women are particularly vulnerable, for both biological and social reasons. Indeed, women below the age of 24 appear to be six times more likely to be infected

than men their age. We are now seeing girls being infected at ever-younger ages.

HIV/AIDS hits people in their most productive years, leaving children and the elderly to do increasing amounts of the work upon which society depends. That means

fewer children can attend school, less efficient farms and businesses, and more

stress on local governments that must divert already inadequate resources away

from development to health care and related services. A generation risks being lost.

More and more children are acting—or trying to act—as caretakers for other children or for the elderly, and more and more families are forced to divert badly needed income for care and treatment of the sick.

As Secretary Powell said on World AIDS Day, ‘‘If humankind is to realize the

great potential that the 21st century holds for prosperity and peace, the global response to this crisis must be no less comprehensive, no less relentless, and no less

swift than the AIDS pandemic itself.’’

USAID’S HIV/AIDS STRATEGY

There are six parts to our HIV/AIDS strategy: prevention; care, treatment and

support; working with children affected by AIDS; surveillance; encouraging other

donors; and engaging national leaders.

First: prevention. This has been the cornerstone of our policy for the past 15

years. The single most important aspect of our prevention strategy is reaching

young people and changing their behavior. Young people are often difficult to reach,

but we have had some notable success working with local organizations to craft a

message that they can embrace. In Zambia, for example, our work with 15- to 19-

year-olds has helped delay the age of sexual debut by two years. As a result, HIV/

AIDS prevalence rates have dropped by 50 percent in this group.

We also stress the importance of abstinence and faithfulness through our faithbased and community-based partners. We have seen in Uganda how effective a partnership of political and religious leaders can be and we have given them our strong

support. And, of course, we distribute over 300 million condoms a year throughout

the world.

We are also expanding our programs that prevent mother-to-child transmission of

HIV/AIDS through the use of antiretroviral medication. Currently, we have them in

Kenya, South Africa, Uganda, Ukraine, and Zambia.

Another important aspect of our prevention strategy is voluntary counseling and

testing, for our experience has shown that those who know their HIV/AIDS status—

and receive counseling if they are infected—are much more likely to behave responsibly than those who do not. They also make for very good counselors and care

givers. So we work with them in programs all over the world. In the Dominican Republic, for example, we fund groups of HIV/AIDS-infected people who support 5,000

others who have the disease, as well as 19 self-help groups.

The second part of our strategy is the care, treatment, and support of those infected by the virus. While there obviously is no cure yet, we can help people survive

longer by treating opportunistic infections such as tuberculosis and continuing to

help countries build up their health care systems and infrastructure. Although prevention remains our primary focus, we have been providing funding for the care and

treatment of people living with HIV/AIDS since 1987. Currently, we have 25 such

projects in 14 countries. One example is Cambodia, where USAID funds an organization known as KHANA which organizes government nurses and staff from nongovernmental organizations to provide home-based care.

26

As the cost of antiretrovirals (ARVs) has declined and the funding we have available has increased, it is now possible to consider incorporating ARVs gradually and

selectively into our care and treatment programs. Accordingly, we have begun identifying potential sites in sub-Saharan Africa where the health care infrastructure is

sufficiently advanced to permit their use. There continue to be a number of challenges we must address before we can make full use of ARV therapies, however.

Among these are the adverse interactions between ARVs and TB medication and the

need for basic laboratory services.

The third part of our strategy involves attending to the millions of children who

have lost parents to HIV/AIDS or are at risk of doing so. I have been to Africa many

times, and I have seen the faces of these children. The fact is we cannot give them

what they need the most—their parents alive and well. But we can do our best to

help them, and we are. We now have 60 projects in 22 countries that provide these

children food, shelter, clothing, school fees, counseling, psychological support and

community care.

In Romania, for example, USAID is sponsoring a modem pediatric AIDS Center

that gives HIV-infected children and families care, support, and counseling. In

South Africa, we are working with the Nelson Mandela Children’s Fund to provide

microfinance loans and community initiatives to support orphans and vulnerable

children. This targets 250,000 affected children.

The fourth part of our strategy is surveillance. The nature of the HIV/AIDS pandemic is that we are always learning new things about it. Just as people’s behavior

differs from region to region, so, too, does the pathology of the infection. There are

now at least 15 different sub-types of the virus that have been identified, and we

fund research with the Centers for Disease Control and Prevention to understand

better their dynamics of transmission.

Through our program with the Census Bureau, we have been tracking HIV/AIDS

data for many years, and our figures have become the standard for the international

community. But it is important that we keep monitoring the disease, tracking our

programs, measuring their impact, developing new strategies with our partner organizations and coordinating our policies with other donor nations. This is the fourth

part of our strategy and one that we must continue to expand.

The fifth component is our ongoing effort to encourage other governments and

multilateral institutions to increase their financial commitments to the fight against

the pandemic. The United States provides one-third of the world’s resources to fight

HIV/AIDS, four times what the next largest donor gives. We also supply one-fourth

of the UNAIDS’ funds and are the largest donor to the new Global Fund to Fight

AIDS, Tuberculosis and Malaria. We have been able to leverage funding from other

governments and foundations as well as coordinate strategies with other donors to

get the maximum benefit from our programs and avoid duplication.

Finally, there is simply no substitute for leadership. Whether the issue is HIV/

AIDS or democracy or building free markets and institutions, the single most important factor in a country’s development is the quality of its leaders and their commitment to their people’s well-being. As our experience in countries like Uganda clearly

show, leadership can make an important difference. So the sixth part of our strategy

is to encourage national leaders to become strong advocates for programs that educate people about the disease and what they must do to prevent its spread. In addition, we work with host governments to develop HIV/AIDS policies, to make the best

use of their resources, and to utilize state media to broadcast prevention messages.

USAID’S COMMITMENT TO FIGHTING HIV/AIDS

USAID has been the U.S. Government’s lead agency on fighting international

HIV/AIDS for more than 15 years. For many years, we were this country’s only federal agency that devoted resources to fighting the pandemic internationally.

In 1986, we provided funding for the global program on AIDS launched by Dr.

Jonathan Mann at the World Health Organization. Our HIV/AIDS budget that year

was just over $1 million; but our commitment has grown considerably since then,

By FY ’01 our budget had risen to $433 million and in FY ’02 it reached $535 million. This means that by the end of this fiscal year, we will have spent more than

$2 billion on HIV/AIDS prevention and care programs. This does not count additional funds that other branches of the U.S. Government are spending on programs

and research.

For fiscal year 2003, I am proud to say that President Bush has requested $640

million for our HIV/AIDS programs. This represents a five-fold increase since 1999.

Over time, USAID has developed an expertise on international HIV/AIDS programs that is second to none. Ours is hands-on knowledge, derived from years of

running programs in over 50 countries. One thing we know for certain: fighting

27

AIDS requires a wide range of technical experts. It calls for pharmacists, teachers,

social scientists, specialists in behavior change, lawyers, as well as doctors, care

givers, and epidemiologists. We have learned many lessons that have helped us

make a difference in people’s lives, and we have no intention of stopping now. We

are continually looking for new ways to make a difference, to shape new programs,

identify promising new techniques and innovative strategies. And as we learn, we

are constantly evaluating ourselves and our programs so that we can fine-tune our

approach.

It is important that we continue to provide a direct link between ongoing research

and those who live in the developing world. An essential part of our strategy, therefore, is to fund the science. Our spending in fiscal years 2001 and 2002, for example,

will total $16 million for vaccine research and another $27 million for the development of microbicides.

We fund applied research in 21 countries. Among the things we are working on

are ways to reach youth—the most vulnerable group—with effective messages about

HIV transmission and prevention; integrating HIV testing into existing health care

procedures; improving programs to prevent mother-to-child transmission prevention;

providing home and community-based care for those affected by the disease; and reducing the stigma of infection, so that those who have the virus can make use of

the services that are available.

In addition, we monitor research that may have practical uses in the field. We

test the findings in small pilot projects and adapt them for use in countries where

they seem most promising. Then we develop the systems, protocols and training necessary to use these approaches on a larger scale so that we can help countries reach

as many people as possible.

TECHNOLOGICAL INNOVATIONS

Over the years, USAID has introduced many techniques and strategies that would

later become standard practices across the world. In the late 1980s, USAID supported the development of simple HIV tests to ensure the safety of blood transfusions. This prevented countless new infections and enabled hospitals to ensure the

quality of their blood supplies.

In 1991, a study in Tanzania showed that treating other sexually-transmitted infections (STIs), such as syphilis and chancroid, reduced HIV transmission by almost

a half. After that, treating STIs became a standard part of our HIV/AIDS prevention

programs. Four years later we began a new approach known as periodic presumptive treatment. This entails foregoing lab tests, which are costly and time-consuming, and giving medication to high-risk populations, such as truck drivers, migrant workers and prostitutes on a regular basis, an approach which has been

shown to reduce STIs significantly.

In 1995 USAID supported a three country study that demonstrated clearly what

many had long suspected—that those who voluntarily undergo counseling and testing and know their HIV/AIDS status are much less prone to engage in unsafe behavior. In many cases, these individuals become powerful voices within their communities. In Uganda, for instance, where great strides have been made in lowering

the prevalence of the disease, more than 500,000 people used these services. We now

have voluntary counseling and testing programs in over 20 countries.

In 1996, USAID played a key role in the creation of UNAIDS. While UNAIDS has

been a forceful advocate for HIV/AIDS funding, their function is not to fund services

on the ground. That is done by individual donor nations such as the United States,

Japan, Canada, Australia, and the Western Europeans.

In 1997 USAID was one of the first organizations to recognize the essential role

that care, treatment and support plays in enhancing prevention efforts. Working

with the World Health Organization (WHO) and UNAIDS, we developed the concept

known as the ‘‘prevention to care continuum.’’ This has now become universally accepted. Prevention, care and treatment are all critical components of an effective

HIV/AIDS program. Care enhances our prevention efforts, reduces secondary

epidemics like TB, and keeps people alive for their families and communities.

In 1998 USAID issued ‘‘Children on the Brink,’’ a paper that focused attention

on the plight of AIDS orphans. This was the first time that many statistics about

these children were published, and it helped reveal another aspect of this terrible

pandemic. Since then, we have launched support projects for HIV/AIDS orphans in

22 countries. An updated edition is expected this summer.

The first treatments that reduce mother-to-child HIV transmission were developed

in this country in 1994, but at the time the process was very expensive and hard

to duplicate in much of the developing world. By 1999, however, new studies revealed that Nevirapine could provide a much more cost-effective approach. The

28

drug, which requires a single dose each for the mother and the newborn child, costs

only about a dollar. And better yet, the drug’s manufacturer, Boerhinger Ingelheim,

is making it available at no cost to developing countries.

PROGRAMS THAT MAKE A DIFFERENCE

Unlike diseases that can be treated by vaccines or antibiotics, the best strategy

available to prevent the spread of HIV/AIDS is to change people’s behavior. Doing

this is never easy, especially when it comes to a subject as delicate and private as

human sexuality. But we have learned techniques that work. Thirty million people

over the last five years have received face-to-face counseling that has brought home

their own risks and taught them how to protect themselves. We are confident that

this has saved millions of lives.

Our mass media campaigns have reached hundreds of millions. And our annual

condom distribution and social marketing activities probably avert a half a million

infections every year.

In the early 1990’s, we worked with the Government of Thailand to make it national policy that condoms be used in all the country’s brothels. This helped decrease HIV and STI transmission rates substantially and has made Thailand one

of the world’s success stories. Lessons learned in Thailand are now being practiced

within Cambodia and the Dominican Republic.

HIV prevalence among pregnant women in Cambodia declined by 28 percent from

1997 to 2000, and the infection rate among sex workers dropped by 57 percent between 1998 and 2000. In the Dominican Republic, too, condom use among the most

vulnerable populations has increased, and men are reporting fewer sexual partners.

Another success story is Zambia, where as I noted above, HIV prevalence has fallen significantly among young people. A USAID-supported youth mass media campaign stressed abstinence for those who are not sexually active and condom use for

those who are. The campaign also produced five television advertisements and an

award-winning music video entitled ‘‘Abstinence is Cool.’’ About 70 percent of the

young people who live in the cities and 37 percent of those who live in rural areas

reported seeing at least one of the ads.

Thanks to the support we have received from the White House and the Congress,

we finally have the resources to begin making a difference on a global scale. As a

consequence we are stepping up the war against the HIV/AIDS pandemic. I have

already taken the first steps, upgrading our HIV/AIDS division to an office and putting it in the heart of our new Bureau for Global Health. Some of you may have

already met the assistant administrator of that bureau, Dr. Anne Peterson. She is

a medical doctor who has spent six years in Africa working on HIV/AIDS and other

issues.

One of my most important management goals is to get more impact out of every

dollar we spend. This means spending more of our resources in the field—where it

is needed—and less of it here in Washington. Resources for field programs will increase from $192 million, or 61 percent, of our budget last year, to $389 million,

or 78 percent, of our budget next year. So not only will we have more money to

spend on prevention, care and treatment and children’s programs, but more of the

money will be spent directly on them.

We are also increasing our HIV/AIDS priority countries from 17 to 23 and adding

substantially to what we spend on them. We have listened carefully to what Congress has been telling us. Sub-Saharan Africa continues to be our highest priority.

Our new plan increases funding to it substantially.

We will also work to strengthen our regional programs so we can focus more strategically on regional ‘‘hot spots’’ where the epidemic is expanding rapidly, as well

as migrant populations and cross-border interventions. We will be convening regional workshops to familiarize our staff with our new strategies. And we are working to establish a comprehensive monitoring and reporting system that will improve

our ability to track the programs in our 23 priority countries.

We are also in the process of creating a central Condom Fund to consolidate our

acquisition, save money, and get them to the field more quickly. This should allow

us to double the number of condoms we purchase.

In addition, we are working with WHO, CDC, NIH and country partners to simplify and standardize treatment protocols. We are assessing the health care infrastructure in a number of countries to determine what needs to be done to introduce

antiretroviral therapy. At the same time, we will continue to support and expand

those low-tech but very effective services that improve the quality of life for people

affected by this epidemic. These include home- and community-based care, treating

tuberculosis, providing microfinance assistance, supporting families caring for addiVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
29

tional children, and supporting organizations of people living with AIDS, giving

them a voice and a seat at the table.

Last May, President Bush was the first to announce a contribution to the newlyformed Global Fund to Fight AIDS, TB and Malaria. To date, the U.S. has pledged

$300 million, and President Bush requested an additional $200 million for the next

fiscal year. Approximately half of that will come from USAID.

We have been actively involved in the formation of the Global Fund from the beginning, and participated in the first official meeting of the Fund at the end of January. USAID loaned staff to the Fund’s Transitional Secretariat for six months, provided $1 million for Secretariat operations, and was key in providing technical guidance on AIDS issues during the formation of the Board.

We believe our experience and programs can serve as useful models for the Global

Fund and can complement its aims.

In conclusion, I would like to emphasize once again how committed USAID is to

stepping up the war against HIV/AIDS. We are in a race against time with a virus

that shows no sign of letting up. As the rate of infection is still growing in many

places, we have to redouble our efforts, speed up our processes, and constantly seek

to refine our approach. While we have recorded some success stories, there are still

many others that must be written. The war on AIDS will be a long and arduous

one, but it is a war that we can, and ultimately, will win.

Thank you.

The CHAIRMAN. Thank you very much.

Madam Secretary.

STATEMENT OF HON. PAULA DOBRIANSKY, UNDER SECRETARY FOR GLOBAL AFFAIRS, DEPARTMENT OF STATE,

WASHINGTON, DC

Ms. DOBRIANSKY. Thank you, Mr. Chairman, members of the

committee. On behalf of Secretary of State Colin Powell, who is testifying elsewhere on the Hill on the State Department’s budget

today, I am pleased to appear before you to discuss one of the Bush

administration’s highest priorities, the global fight against HIV/

AIDS, tuberculosis, and malaria.

As you very correctly pointed out in your opening remarks, the

spread of HIV/AIDS continues unabated with some 8,000 deaths

per day and 5 million new infections last year alone. There are 40

million people living with HIV/AIDS worldwide, nearly 3 million of

whom are children under 15 years of age. We simply have no

choice but to confront this pandemic.

Mr. Chairman, our battle against the HIV/AIDS, TB, and malaria pandemics is made easier by the steadfast support we have

received from you and your colleagues on both sides of the aisle

and in both houses of Congress. Simply holding this hearing today

is critical in raising awareness and manifests how both branches

of Government can and must work together if we hope to staunch

the spread of these diseases, treat their victims, and find cures.

Two of your committee colleagues, Senators Frist and Kerry, deserve, I may say, special mention for their involvement with the

work done by the Center for Strategic and International Studies on

HIV/AIDS, work in which my colleagues and I have participated

very directly and from which I know not only myself but others

have benefited greatly. Many of your colleagues in Congress, including those on this committee, have played vital roles in backing

the bilateral programs implemented by USAID and the vital work

done by HHS and its agencies, as well as in facilitating the startup of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

30

Mr. Chairman, I want to underscore this administration’s commitment to this battle. Under the leadership of President Bush, the

U.S. Government continues to be the global leader in the fight

against HIV/AIDS. As Secretary Thompson referred to in his testimony, President Bush made the first pledge to the Global Fund by

any government, and his request of an additional $200 million for

the fund in fiscal year ’03 sets an example for other governments

and potential donors. The half billion dollars this administration

has committed to the Global Fund constitute the world’s single biggest source of support.

Last fall, the President came to the State Department for the

Forum on Africa Growth and Opportunity Act and talked to the

participants about AIDS in Africa. He included the fight against

AIDS in his speech to the UN General Assembly. Also, he established a cabinet task force on HIV/AIDS, which is co-chaired by

Secretaries Powell and Thompson, to coordinate his administration’s efforts and to signify its high level of engagement. Like Secretary Thompson and Administrator Natsios, Secretary Powell has

invested vast amounts of time and energy to this cause, for instance, having toured Africa last May where he saw firsthand the

devastation these diseases have caused there.

In fact, last fall, to bolster and coordinate our fight against infectious diseases, Secretary Powell created a new Deputy Assistant

Secretary position for International Health and Science in the Bureau of Oceans, Environment, and Science, a post filled by Dr. Jack

Chow, who is here with me this morning. Dr. Chow was our chief

representative at the negotiating sessions last fall of the transitional working group, the precursor to the Global Fund, with a delegation that included representatives from HHS, USAID, and the

Department of the Treasury.

Dr. Chow spearheads an interagency working group that meets

frequently to ensure that the U.S. approach is fully coordinated.

This working group got started last fall in connection with the

work on the Global Fund and will continue to meet on the fund as

well as on bilateral programs. Indeed, the State Department works

closely with other Government agencies and Departments, including USAID, HHS, CDC, and others, which contribute their own

widely sought technical support, expertise, and experience.

Let me say a few words about the fund. The Bush administration

views the creation of the Global Fund to Fight AIDS, Tuberculosis,

and Malaria, which held its first board meeting last month, as one

of the most promising steps in this 2-decade-old battle. The Global

Fund, established as an independent foundation under Swiss law

and based in Geneva, was created in record time by an unprecedented public/private partnership and thanks to the tireless efforts

of a number of people here in this room today.

In approaching the establishment of the Global Fund, the President outlined a vision for what was needed for it to be most effective. All of the parameters we set forth during the negotiations on

the fund were agreed to, and I would like to just share a few with

you.

That the fund be based on a public/private partnership.

31

That the fund scale up the international response to these diseases with an approach that would complement, not compete with,

existing international and bilateral programs.

That it promote an integrated approach, emphasizing prevention

in a continuum of treatment, care, and response.

That it operate according to principles of proven scientific and

medical accountability.

That it focus on best practices proven to work in the field.

That it involve developing countries in the design and operation

of the fund and in the projects to ensure ownership.

That it ensure respect for intellectual property rights as a spur

to research and development.

We are pleased that the preparations leading to creation of the

fund, as well as the operations of the fund itself, have been conducted in an open and transparent manner, with a strong emphasis

on attaining financial and program accountability.

Along with governments, NGO’s, foundations, and the private

sector were represented in the transitional working group that met

three times last fall to establish the principles and operating mechanisms for the fund. Some of those participants continue to serve

on the fund’s board. Secretary Thompson already outlined the 18

voting members, including seven donor countries, seven developing

countries, two NGO representatives, one foundation representative,

and one for-profit private sector representative. In addition,

UNAIDS, the World Health Organization, and the World Bank, as

the fund’s fiduciary agent, as well as a third NGO serve as nonvoting members.

I am delighted that the fund’s board issued a call for proposals

just last week and hopes to announce the first grant awards at its

next meeting in April, which will be held in New York City. The

board will have the final decision making authority on proposals.

It will benefit from a technical review panel composed of experts

in a variety of disciplines and serving in their independent capacities to review all proposals to ensure that submissions are based

on best practices and are technically sound.

Proposals will come from partnerships of Government, NGOs,

and the private sector through what is called a country coordinating mechanism. Significantly, where such partnerships are not

possible, NGOs will have the right to submit proposals directly to

the fund. Proposals from those countries and regions with the highest burden of disease and the least ability to bring financial resources to bear will receive highest priority. Proposals from countries and regions with a high potential for risk will also receive

strong consideration.

Because HIV/AIDS, TB, and malaria know no boundaries, the

fight against them, to be successful, must be waged on a worldwide

scale. Accordingly, recipients of fund grants will not be confined to

one region of the world at the expense of other regions. Nor will

the fund focus on just one disease. As the name of the fund itself

reveals, it targets AIDS, tuberculosis, and malaria. There are no

set limits on how much of the fund’s resources will go toward either a particular region or toward one of the three diseases. The

U.S. approach has been to afford the fund’s board maximum flexiVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00035 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
32

bility in responding to proposals that come in from around the

world.

The Global Fund is to complement significant bilateral programs

of the United States as well as the bilateral programs of other

countries and the efforts of the UN agencies and the World Bank.

It is not a substitute for these efforts that are already underway.

It will dispense the money it provides as grants, not loans. While

the fund will be fully independent of the UN, it will benefit from

and work with the UN agencies charged with improving global

health, such as the World Health Organization and UNAIDS. Of the $1.9 billion that has been pledged to date, some over sev- eral years, we expect $700 million to be available this year for disbursal. As you know, our contribution totals $300 million so far

and President Bush’s budget proposes adding another $200 million

for next year.

The President announced the initial U.S. pledge last May in a

Rose Garden ceremony with Secretary-General Kofi Annan, to

whom we do owe a debt of gratitude for his tireless work, as we

do to Dr. Peter Piot, who will be testifying next. At that ceremony,

the President stated: ‘‘The devastation across the globe left by

AIDS, malaria, and tuberculosis, the sheer number of those infected and dying is almost beyond comprehension. Only through

sustained and focused international cooperation can we address

problems so grave and suffering so great.’’ In sum, that is why the

fund is so important.

In conclusion, Mr. Chairman, there is, of course, a great deal of

work still to be done, and the best indicators of our success will be

the decline in deaths from and spread of AIDS, TB, and malaria.

We cannot afford to take a deliberate approach for one simple reason: the fight against these diseases cannot wait.

AIDS alone has left at least 11 million orphans in sub-Sarahan

Africa, and in several African countries, as many as half of today’s

15-year-olds could die of AIDS. By 2010, the Asia/Pacific region

could surpass Africa in the number of HIV infections. The fastest

rate of HIV infection in the world is in Central and Eastern Europe

and Central Asia. The disease is also spreading in regions close to

home, particularly Central America and the Caribbean. Tuberculosis claims almost half a million people a year in India alone.

Malaria, long thought to kill a million people a year, mostly young

children, may actually kill up to 2.7 million people each year.

Time is not on our side and we must resolve to move as expeditiously as possible. Human lives depend on our ability to get the

funding underway in an effective and successful fashion. Congress’s

role in this endeavor is critical, and that is why this hearing is so

timely and so important.

Thank you.

The CHAIRMAN. Thank you very much.

Obviously, we cannot fund a good audio system in this room.

Ms. DOBRIANSKY. I tried to speak loudly.

The CHAIRMAN. No. It is not you, it is us. We are the world’s

greatest economic engine, and we do not have microphones that

function. I apologize.

Let me ask both of you, because there is a good deal of confusion

that surrounds the Global Fund. When the Secretary-General of

33

the United Nations called for a fund of $7 billion to $10 billion, he

was calling for the need for $7 billion to $10 billion a year being

spent to combat this disease. I think the vast majority of people

who are aware of that, even reporters and those reading the newspaper and watching television, assumed that that related to this

Global Fund. Then when they see that there is $1.9 billion pledged

or in that range, the conclusion reached is that the world is vastly

underfunding the need on a yearly basis. Notwithstanding the fact

that we are funding roughly 50 percent of all the money being

spent on all efforts worldwide, including here, relating to AIDS, we

quite frankly look like pikers when the number comes up of what

we are committing relative to the need.

Would one of you try to rationalize for me those numbers and

those percentages so we can, at the outset, get a clearer picture of,

(A) what is needed, (B) what the world is spending relative to the

need, and (C) what we are doing relative to our share and responsibility of leading the world on this issue?

Mr. NATSIOS. Let me first say that the total amount that the

United States Government will be spending, both bilaterally

through CDC, through State, and through AID—the Defense Department has a small program; there is a small amount from Labor

as well—next year will be $1,117,000,000. That is what is in the

budget. Of course, we do not know what Congress will give us, but

usually they do not give us less.

The CHAIRMAN. We usually give you more than you ask for.

Mr. NATSIOS. Yes, you do. That is correct.

The CHAIRMAN. So, go ahead.

Mr. NATSIOS. That includes our contribution to the Global Trust

Fund. So, internationally the amount that we will spend at a minimum next year—I expect it will probably be higher, but what we

have proposed is $1,117,000,000.

The CHAIRMAN. Now, how firm do you think the number attributed to the Secretary-General is which, as I understand it, is between $7 billion and $10 billion? What do we assess, if we were

making such a judgment, is needed worldwide? Is that a number

that makes sense? If it is $10 billion, we are contributing over 10

percent a year of the need, not actually committed, and if it is $7

billion, we are committing over one-seventh of all that is needed.

The reason this is so important to get on the record at the front

end here is to give the American people a sense of the degree to

which we think it is a problem, the degree to which we are responding to the problem, and the degree to which the problem remains unresponded to in the rest of the world.

Mr. NATSIOS. Let me add a few other comments in terms of this

issue.

The CHAIRMAN. Please.

Mr. NATSIOS. The first is that we should not see the trust fund

as the only or even primary mechanism for responding to the pandemic. Is it one of many mechanisms. The front-line troops are the

ministries of health in these countries. The medical doctors, the

public health professionals in the ministries are the ones who have

to lead the charge. The second group is the NGO’s that do international health programs in these countries.

34

There are UN agencies that spend money directly from their own

fund. UNAIDS, for example. You are going to hear from the Director of that program. We give money to that. Now, that is not included in the money we give to the trust fund because it is a separate account.

In fact, WHO also has programs in various areas.

There are specialties in different institutions. For example, CDC

are the best in terms of surveillance from the biological side of surveillance. So, we rely on them in the field. They have set up laboratories. I have visited the laboratories and seen the work they do

in actually testing blood and that sort of thing and watching the

spread of the disease, examining the 15 different subvariants of the

disease that have developed. We do the surveillance on the public

health side, on the behavioral side of it.

A lot of the coordination that you asked about earlier in fact

takes place not in Washington or in the UN agencies. It takes place

in the capitals of the countries that are fighting the disease because there are different problems in each country.

The CHAIRMAN. I would like to get to that later.

Again, I want the record set straight so we are all singing from

the same hymnal and the same page of that hymnal. When you

hear criticism—each of your departments—when it occurs that we

are not doing enough, that the degree to which we are funding is

insufficient, et cetera, it is a useful thing for us to factually understand the context in which what we are doing contributes to the

solution.

So, when I travel around the world, I will occasionally get lectures on why we are not doing more on this particular issue, and

yet, when you look at the overall numbers and you look at the percentages of the total expenditure that impacts upon the problem

worldwide, maybe we should do more, but we are doing the lion’s

share relative to any other single entity in the world.

It is important for you all to lay that out because, as the doctor

and I were saying earlier, we focus on the Global Fund as if that

is the totality. When the Secretary-General says the problem is a

$7 billion to $10 billion problem a year and you look at the Global

Fund and the total pledges do not come anywhere near that, then

the conclusion that reasonable people could reach, if that is all the

information they have, is wow, we obviously are not very serious.

Yet, you tell me, and you have said in your testimony, that

$1.117 billion is requested for fiscal year 2003. I am telling you

that I expect that will be higher. So, somewhat in excess of $1 billion to what is labeled a $7 billion to $10 billion problem a year

is going to be committed by the United States of America. At least

for reasonable people, it should change the attitudes a little bit

about whether or not we are being responsible.

What I am trying to do is make your case for you. You are not

making it very well. Let me help you a little more.

Mr. NATSIOS. Thank you, Senator.

Mr. ALLEN. Mr. Chairman, if I may try to address that for you.

The CHAIRMAN. As a former staffer, you probably know how to

do it better.

Mr. ALLEN. Thank you.

35

One of the things we cannot fail to realize is in addition to the $1.1 billion that is being requested directly from the administration

to fund, we have also left out those funds that are being put into

this global issue through U.S.-based NGO’s, through the private

sector, and particularly in terms of the antiretroviral treatment.

The pharmaceutical companies are putting billions of dollars either

by, one, providing free the antiretroviral therapies or cutting their

costs significantly, some even 90 percent of cost. So, I think that

you are actually right.

Let us assume the worst case scenario of Secretary-General

Annan’s estimates of $10 billion a year. At a minimum, the United

States is doing in excess of 10 percent of that, whereas we are providing that. I think that the estimates would be much higher than

that when you take all in total what our nongovernmental organizations are putting in as well as what the private sector of the

United States is putting in as well.

The CHAIRMAN. I am not suggesting we do not do more. I think

we should do even more. What I am trying to get at here is a baseline so that we are all again speaking from the same baseline, so

we know what is going on here. That is the reason I asked the

question.

Mr. NATSIOS. Senator, let me add to the comments I made. You

asked me whether we think this figure is right. We do not have a

precise figure. We do not now for sure. There are some countries

where the rates may be higher than we realize or lower than we

realize. These are sort of global estimates.

We think in AID that the Secretary-General’s estimate was a

reasonable one. Let me say that first.

Secondly, I have always believed, doing this work over the last

13 years, that you do not put all your humanitarian or development eggs in one basket because if you put it into one institution,

whether it is a bilateral institution, international institution, a national institution, and it fails, you have a lot of people who die. So,

having multiple actors who coordinate with each other and work

together is a much better approach because then whoever is most

successful, whichever institution moves most rapidly is the one

that should get more funding. If this trust fund works as well as

we hope it will, we should put more money into it, but it has not

proven itself yet.

Some international funds have been remarkably successful over

the years, without mentioning names. Some have been remarkably

unsuccessful. We think this one is going to be a successful one, but

it has yet to prove itself.

The CHAIRMAN. I have a whole line of questioning. I would like

to get into the coordination issue and how we measure success and

how we measure failure.

But what I am trying to focus on now is the simple proposition

that in terms of gross numbers of what is needed, I think most

Americans would think that we have been behind the curve, as we

are I might add in a lot of aid programs in other areas behind the

curve relative to other countries in terms of their percent of GDP

and the like. So, I just want to get a sense of where it is coming.

With the permission of my colleagues, I will follow up with one

question, even though my time is up. Can you give me, any of you

36

or all of you, an assessment of why you think, if my perception is

accurate, other G–7 nations and the EU generally have not, in relative terms—or have they in relative terms—made similar commitments to this worldwide fight on AIDS? Have they? And if they

have not, do you have a sense of why? Is it just not viewed as urgent? Or can you give me some sense or feel? This is not to say

who are the good guys and bad guys. We are trying to get a sense

of what kind of urgency has to be created worldwide in order to be

able to do what we are by any standard as a world not doing nearly

enough to deal with it.

Ms. DOBRIANSKY. Senator, if I may comment.

The CHAIRMAN. You can call me Mr. Chairman. That is OK.

Ms. DOBRIANSKY. Mr. Chairman, thank you.

The CHAIRMAN. It may not last, but you can call me that.

I know it is hard for a Republican to say that, but give it a shot.

Ms. DOBRIANSKY. I think that one of the reasons that maybe we

have not seen others being as forthcoming as we would like to see

them is I think a point that Andrew referred to, which in a way

has impacted our own contribution to the fund. That is, the point

that the fund is but one instrument in this effort. There is the expectation that we look toward its success. There is the anticipation

that it will be successful, but there may be other countries that

may be hesitant, trying to anticipate what its success will be.

In terms of bilateral efforts, I personally believe that we need to

be more vigilant. In fact, I know that the Secretary of State has

used every means—bilateral meetings, multilateral fora—with

which to get this point across and drive the point home, that this

is an urgent issue. It is one that we all must have a stake in and

which we all must address.

But I would say with respect to the fund, some of the lack of

movement may be grounded in the Fund not yet having a proven,

successful track record.

Mr. NATSIOS. Let me add. Most of my friends in Europe who are

development ministers who have the same portfolio I do—we talk

about these things. We have an annual meeting called the Tidewater meeting that has gone on for decades that is development

ministers off the record speaking. The Europeans do take a different approach to health problems than we do. We take a diseasedirected approach. In other words, we will target malaria or tuberculosis or HIV/AIDS. They take a health systems approach. We do

that too, but if you looked relative to the amount of money we

spend, Congress has preferred—and AID agrees with this approach—that a disease-focused approach is a better one.

It is legitimate disagreement. We do not have yelling matches

over this. In fact, they complement each other. They put more

money into systems. We put more money in fighting specific diseases, but we need the systems to do that. So, the two actually

complement each other in many ways. So, the Europeans will say,

if they were here, well, you are being a little unfair to us. We put

the money into systems.

I might also add our other health programs are also integrated

in our programming in the field. We do not have programs that are

sort of isolated from the rest of the mission. We do a country strategy in each of the 75 countries we are in, and there is a health

37

strategy which includes HIV/AIDS. It also includes population,

women’s health, and child survival programming. Those get woven

together and they all affect each other because we know that, for

example, by the antiretroviral nevirapine being administered once

prior to a woman delivering, we can reduce more than 50 percent

the transfer of the infection to her newborn child. Well, that is also

a child survival program. So, we are looking at this sort of in a tunnel way, when in fact the reality in the field with the ministries

of health, with the NGO’s, and with the AID agencies is a much

more integrated approach.

The CHAIRMAN. That was the point I was trying to get at because

I am not in any way criticizing or castigating Europeans or anyone

else. I think it is important, this notion you have just put forward,

this sort of holistic approach, that we are as a community and the

industrialized world actually paying more attention to this collectively than is essentially given credit for.

We are not looking for credit. We are looking for a sense of cooperation. There is a whole range of issues that are north-south

issues, that if we could communicate more accurately the degree of

the concerns, we would also impact on the political side of this

equation as it relates to things having nothing to do with AIDS or

health issues. That is why I raise it.

But I will come back because I have gone over my time. I thank

my colleague. I yield to the Senator from Tennessee.

Senator FRIST. Thank you, Mr. Chairman.

I want to continue a little bit on the question that I started with

Secretary Thompson, or without him here or the Secretary of State

here, instead of talking about cabinet level organization and focus

at that level, I would like to explore what has been fascinating to

me, and that is the relationship between the CDC and USAID on

the ground.

Most of the people on this particular committee understand the

importance of being on the ground, traveling to the various countries around the world, talking to real people, seeing what the policy or the money that we have been talking about actually translates into.

Mr. Natsios, in your written testimony, you stressed the importance of not just spending money and seeing money is allocated

here, but to make sure it gets down to the local level where very

successful programs, again that you outlined, like voluntary counseling and testing, we know works. We know it works. The problem

is a lot of times our support, our intentions do not translate to onthe-ground. That is why I try to get to Africa every 6 months to

a year and try to go and look at individual programs and talk to

real people. The answers are there. Now we need to highlight them

and make sure they are adequately supported.

I mention all of that because about 3 or 4 years ago, when I went

to Kenya and I think it was Uganda the other day, comparing the

relationship between the CDC and USAID, it seems to be different.

I cannot figure it out yet. So, I would like for maybe Mr. Allen and

then maybe Mr. Natsios, both of you, to explain to me your perception of the relationship between what the CDC is doing and what

USAID is doing. Are they duplicative still at all, or through conVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
38

tract relationships and working side by side, are those differing

roles beginning to merge in a more coordinated way?

It is clearly different, for example, in Kenya now versus 3 years

ago, and in Uganda the same. A tremendous success story. We

spent about $120 million there over the last 10 years of taxpayer

money, last year probably $25 million. Those are very rough figures. By CDC and USAID working together on the ground, supporting programs like VCT, voluntary counseling and testing, we

have seen a 30 percent incidence of infection go to 6 percent or 7

percent. That is dramatic. A good investment for the American people and for the support of issues like the Global Fund.

My question after all of that is basically what is the role of CDC

and USAID on the ground, and are they working hand in hand as

effectively as they might?

Mr. ALLEN. From the HHS perspective—I think probably all

three would share this view—on the ground we take direction from

the ambassador. So, therefore, the State Department takes the lead

in government relations there.

From HHS’ perspective our relations differ in some sense—are

not duplicative of what USAID does in that we work directly with

the public health system, the public health service in country. Unlike USAID, CDC does not do direct contracting. We do not contract with providers. We have to work directly with the public

health authorities. So, therefore, any country in which CDC is operating, we would have somebody on the ground working through

the public health system in that country to develop capacity to provide infectious disease surveillance, response, training, but we do

coordinate our activities very closely with what USAID is doing on

the ground. So, I think just starting with that, it really is a different role because what we are required to do under statute, what

we do not have authority to do on the ground.

Senator FRIST. How many countries, HIV/AIDS-related, is the

CDC in right now?

Mr. ALLEN. We are, right now, in 18 countries, and by the end

of the year, we will be in 25.

Senator FRIST. Mr. Natsios?

Mr. NATSIOS. Yes. Let me sort of go over the two respective specific focuses or ways we operate. We have a written memorandum

of understanding. It is several years old. If you wish a copy of it.

It goes into some detail as to what we do and what CDC does.

Senator FRIST. Can I ask you one question just so I can keep it

in the record about the same?

Mr. NATSIOS. Sure.

Senator FRIST. They are in 18 countries now, HIV/AIDS-related.

How many countries are you in?

Mr. NATSIOS. We are in 17 countries. We will be in 23 countries.

This is in big programs, in major focuses. We have programs in a

lot more countries that are more modestly sized.

Senator FRIST. That is helpful.

Mr. NATSIOS. CDC has expertise in disease surveillance. In fact,

when we designed the disaster assistance response teams in OFDA,

which you are familiar with, 10 years ago, there is a specific seat

for CDC on that DART team. So, we take them to the field with

us in most major emergencies, whether they be natural disasters

39

or famines because they set up the surveillance system for us. We

have money, for example, the $600,000 in the Afghanistan budget

for CDC to set up a surveillance system for disease in Afghanistan.

We do not want to replicate that.

The second thing they do very well is on blood supply safety. You

know that is one of the way in which the disease spread in the

United States in the early years and continues in many countries

because there are not adequate systems in place to test the blood.

CDC has expertise in that that we do not have. We do not want

to develop it. So, they do that.

They also have laboratories in which they conduct clinical studies

in the field, once again, from sort of a biological standpoint.

Our expertise in AID is in public health. We have hundreds of

people with master’s degrees in public health or Ph.D.’s. We have

a lot of medical doctors too. But the focus in AID is community

health prevention in all our programming, not just in HIV/AIDS.

So, on the prevention side, we actually work through the ministries of health, NGO’s, faith-based communities, and community

groups and private contracting companies. We will hire private

companies that will go in and do social marketing for us. If we

want to do an advertising campaign, we do it with the ministry of

health, but they actually come in and design the advertisements

with the ministry of health’s approval for billboards and radio ads

and posters. If you go to many countries and you see them, if you

look very carefully, at the bottom it will say it is an AID funded

project. That is one of our great strengths. Those programs are successful.

We will give grants to NGO’s to create a mechanism for community-based counseling for teenagers, for example. We do after school

programs through the mosques and the churches and through the

NGO’s to counsel teenagers on postponing their sexual debuts.

That is the term used by the clinical people. It is not my term.

That has a profound effect on infection rates. We know that works.

We are expanding that.

We just did an Africa-wide——

Senator FRIST. Let me just say that has been hugely successful,

having been on the ground again, to see that that delay of 18

months or 2 years radically changes both behavior after that period

of time but also during it.

Mr. NATSIOS. It does.

Senator FRIST. I just want to commend you because it is one of

the great successes.

Mr. NATSIOS. Thank you.

We also do a lot in the treatment of STD’s. We know that sexually transmitted disease, if you have it and then you are exposed

to HIV/AIDS, there is a dramatic increase in the incidence of infection. So, if you treat the STD’s, you reduce the spread of the infection of the HIV.

Senator FRIST. I am going to ask you to speed up. We are in the

middle of a vote. So, I am going to go in a second. Go ahead and

make your final point.

Mr. NATSIOS. In any case, so they are program design, program

implementation. They tend to not be laboratory centered but on the

prevention side and the public health side.

40

Senator FRIST. That is helpful.

Mr. NATSIOS. But we have a detailed MOU on that. We have had

it for several years, and it goes into some detail as to what we do

and do not do.

Senator FRIST. That is good. That is very helpful.

The Chairman I think in the point he made initially, in terms

of the overall global spin, I think is important. It more addresses

policy makers because we, like all of you, are traveling around the

world answering questions. I think most of us think we need to put

a lot more money in, but we need to really be able to document

where we are putting money now, how much, as well as do what

Jeffrey Sachs and others we will hear tomorrow about defining the

big, big problem. I think that is a useful exercise for us.

Let me jump to something conceptually again. The Global Fund,

as important as it is, does not reflect the overall efforts of the

United States. It did not exist a year ago. There have been no programs approved. Yet, we have already committed or intend to commit $500 million, and that is a third of the fund. So, I think we

ought to put more in it and I am going to argue for it. Yet, people

do have to remember that fund did not exist a year ago. There

have been no programs approved. The applications are just not out

there. So, we need to do it in a step-wise, systematic way.

Right now we have got the CDC. We have got USAID that have

been in the field. I have seen the programs work. Some do not

work. We need to move beyond those. On the Global Fund, we do

not know if it is going to work or not. We are trying to construct

it in such a way with the right oversight. When people say why do

you put money in the Global Fund, why not put it in the programs

like CDC, USAID who are in the field already working—so my

question is how you answer that, number one.

Number two, as we spend out of the Global Fund, will this

money end up coming in part back to CDC, USAID type programs?

Will some of that money that we are spending there, through the

applications being made, feed back to the support of CDC, USAID

on the ground?

Ms. DOBRIANSKY. If I may answer this. First, I think the fund

has, even in its present state since coming into being January 1 of

this year, significantly elevated global awareness and consciousness

of HIV/AIDS, tuberculosis, and malaria.

Second, I think we have already referred to the importance of a

diversified approach. In this case, I think the great value of the

fund is that you have a global response. You have a diversified set

of stakeholders coming together in support of an urgent issue, one

that must be dealt with, one that deserves a remedy and a quick

one.

Third, I would say that it is also very unique in terms of the public and private partnership. The fact that proposals are being solicited, are open to country coordinating mechanisms, which I referred to in my testimony, which basically pull together not only

government entities but elements of civil society—the full scope of

civil society. As you very well know, that is the most effective strategy to combine all efforts together, not just one. I think in that regard, our investment is a very worthwhile one for all of these reasons.

41

Mr. NATSIOS. Senator, if I could just expand on that just slightly.

The fund will allow us in addition several benefits. It is the same

rationale for GAVI, the Global Fund for Vaccinations and Immunizations, and that is economies of scale in terms of purchase. You

know when you do volume purchases, you can get the price down

per unit of what you are purchasing. The Global Fund will allow

us to do that. While we do huge purchases—we will purchase 500

million condoms this year, for example—if you buy 3 billion, you

obviously get a lower price and you can set up logistics systems for

distribution that can be very useful. So, there are economies of

scale that will allow us to reduce costs per unit.

The second is that we are providing and will continue to provide

technical assistance to the applicants to the fund to make sure that

their proposals are going to meet the standards that have been set

up that everybody has agreed to. The southern countries have

agreed and the northern countries have agreed what the standards

are. We want to make sure that the institutions that we think have

the execution capability, the implementation capability actually

write the proposals so they get through this process properly. We

are providing technical assistance to them to do that.

We are not going to apply. AID will not apply for any money in

the fund. That would be self-defeating.

But it is also the case, I might add, that the way this will work

is many ministries of health will work with local NGO’s jointly to

do proposals. The NGO community does not get one grant. Having

been in the community for 5 years, I can tell you how it works. You

do not get one grant from one donor and that is your program. You

can get 10 donors to give money toward one huge program in one

province, and you put them all together. You piece them together.

There is one common program design, but you get multiple donors.

That is what the UN agencies do too.

I expect some of the NGO’s and ministries of health that are getting money from this fund are also getting resources from either

CDC or from us at the country level. The benefit is, again, this

economies of scale once again.

Senator FRIST. Let me move on. I think that has been very helpful to me, the whole discussion on the relationship between the

two.

Madam Secretary, I appreciate you mentioning the CSIS project

that many people in the room and many people on this committee

are participating in, which is a longstanding project looking at a

number of the issues that we can touch upon in these hearings but

we do not have the time to really go into much more depth. So, I

look forward to continue working with many people in the room on

that.

We have three panels today and we are in the middle of a vote.

I am going to leave in about 2 minutes, and the chairman is on his

way back. So, we may suspend for bout 3 or 4 minutes.

But the issue of treatment is fascinating when you are on the

ground. We have already talked a little bit about it, the

antiretrovirals, which from sort of the north standpoint, western

standpoint, are very effective. We do not have a cure for HIV/AIDS.

We need to keep saying that. It is an incurable disease as we know

it today.

42

Then you start thinking of linking prevention, care, and treatment. Again, as a physician, you have got to have care and treatment part of this equation. Prevention is where the answer is because we do not have a cure. Behavior is where the answer is for

the time being, but the care and treatment opens up hope. It brings

people in. The rapid testing, revolutionary because technology has

made that possible over the last 6 months where you can come in

and in an hour, a teachable moment because of this new test that

costs about $1.20 instead of a $335 test which would take 2 weeks.

To me it shows where this merger of technology, social policy,

teachable moment all come together and has been very successful

to date.

The antiretrovirals are a big part of potential treatment, but you

have to look at some basic things like the treatment for opportunistic infections, other sexually transmitted disease, nutrition, all of

which we know also does what antiretrovirals do, and that is prolong life and in many cases even in a more powerful way. So, we

cannot just focus on the antiretrovirals.

With that, could any of the three of you—actually I am going to

leave. So, I am going to throw that question out there. When the

chairman comes back—I know we have got two more panels to go,

but I would ask that you stay for a few minutes because I am sure

he will have one more round of questions with you.

But this issue of treatment—and my question is going to be what

is the CDC doing, what is State doing, what is USAID doing in

terms of programs to look at this more complex, comprehensive,

really more intricate way of treating which in truth is equally important, I would argue, to antiretrovirals today.

With that, I think we will suspend, though we will start back

within about 5 minutes. Thank you.

[Short recess.]

The CHAIRMAN. We will come back in session, please.

Senator Frist has a few more questions, as I do. The reason I left

early is to be able to go vote at the front end here and he is now

voting. By the time I finish my questions, he will be back and will

ask his questions. Then we can release this panel, which has been

very, very helpful to us. I appreciate it.

Mr. Natsios, I would like to ask you, as well as anyone else who

would like to respond. I have been told that less than 50 percent

of the African countries have adopted a national blood transfusion

policy, and less than one-third of the African countries have a system in place to limit HIV transmission through blood transfusions.

The first question I have is, is this accurate, to the best of your

knowledge, or do any of you know?

Mr. NATSIOS. We believe it is pretty close to accurate, Senator.

The CHAIRMAN. What programs does the United States have to

ensure, if there are any, that developing countries, particularly in

Africa, are able to put in place systems for handling blood supply?

Are we working with individual countries? What are the programs

we have?

Mr. NATSIOS. CDC runs the programs that set up the laboratory

systems to do the testing with the ministries of health. In the countries that they have been able to do this, I understand that they

have been successful in treating and testing. I am less familiar

43

with the details of how the laboratories work. I visited a couple of

them.

Mr. ALLEN. Through the Food and Drug Administration and the

Department of Health and Human Services, it really has the focus

on protecting the blood supply. We work in coordination with CDC

and countries, but we also work with NGO’s, such as the American

Red Cross, to ensure safe blood supplies. So, working on the ground

in those countries, we are being very effective in addressing and securing the blood supply, and that is a critical step in stemming the

tide of the spread of HIV/AIDS, but also in bringing down the risk

associated with others contracting the disease through tainted

blood.

The CHAIRMAN. Do we have any sense of to what degree, if any,

the transmission occurs through tainted blood in Africa or generically? In other words, if you have 50 percent of the countries,

roughly, that do not have anything in place that would in any way

be able to guarantee the blood supply, particularly as it relates to

the transmission of AIDS, do we have any sense of how big a problem that is as a percent of the problem?

Mr. ALLEN. I do not have those numbers. We can certainly get

that information for you.

Mr. NATSIOS. It is about 5 percent, Senator. Five percent of the

incidence of HIV is attributable to blood transmission, that is,

transmission through blood supply. As you can see by the 5 percent, it is not the predominant problem.

The CHAIRMAN. No, no.

Mr. NATSIOS. It is a problem but not the predominant problem.

The CHAIRMAN. But it seems to me that it may be one of those

problems where you could—nothing is easy. You have at least the

theoretical capacity to close that window of 5 percent, whereas you

cannot quantify and/or be as certain that you can do that as easily

with regard to teaching abstention or other things that are not as

measurable, not as easily measured. That is why I raise the question.

Mr. NATSIOS. There are actually four or five countries now where

we do have programs that CDC runs. We do not run them.

Mr. ALLEN. Right. We have programs currently in India, Kenya,

Uganda, Tanzania. I do know that while in New York at the Global

AIDS Summit, we had discussions with the Chinese who were very

interested in looking at what the United States was doing in terms

of our blood safety programs. Others are looking to the U.S. and

our Government agencies to work in those areas of securing the

blood supply.

The CHAIRMAN. Is there any institutional or infrastructure and/

or cultural resistance? Is there anything preventing us from assisting in improving blood supply systems other than we just have not

been able to get to it yet? I am not focusing on this as any failure.

I am just trying to get a sense of whether or not there is any reason, other than just not being able to—because this is such a gigantic problem—get to it more effectively, more quickly? Or does it relate to dollars? Does it relate to infrastructure in the country?

Mr. ALLEN. I think it goes to all of that. I think part of it is infrastructure. If you cannot store blood, if you cannot test blood, if you

do not have the laboratory facilities to assure that, that is all part

44

of the problem. Of course, money goes to the heart of that in many

ways.

The CHAIRMAN. That is why I was asking.

Mr. ALLEN. I would think it is less of the former, the cultural differences that might exist. I think it is really technology.

Mr. NATSIOS. If I could add a couple of things. We are doing very

extensive use of this rapid testing. It was AID field research that

discovered that a rapid test will double the number of people who

go into the clinics to get it done. If you use a rapid test as opposed

to a test that takes days for the results to come back, if they get

the results immediately, the number of people who are willing to

go in and be tested doubles. This is true in the United States. It

is true in the developing world. It is just a part of human nature.

If you can do the tests rapidly and people know, their behavior

does change fairly quickly for a large number of people. So, that

can stem the spread of the disease.

In some countries, Senator, there is not a very large blood supply, I have to tell you, because there are not large hospitals. There

health systems are more clinic-based and preventive-based as opposed to treatment in terms of surgery and that sort of thing. So,

you will find a lot of countries without large blood supplies where

this is an issue.

The CHAIRMAN. That was my next question.

One other thing I would like to ask you about is to the extent

that you can characterize it with any degree of certainty or accuracy, how widespread—let us start with the continent of Africa,

which is obviously a gigantic continent and is as diverse as any

other continent in the world. But we have been focusing a little bit

on it. How widespread do you believe among the populations at

large is the knowledge of the extent of the virulence attached to

and the method by which the disease is communicated in terms of

just public education? How much awareness is there? I am not

talking about the government level. We always talk about the government level and whether governments are willing to admit to or

acknowledge or deal with it, et cetera. I am not talking about an

official response. I am talking about if you were to walk into a lowincome area populated with 750,000 people and you asked about

HIV/AIDS, would you find an awareness as to the extent of the disease, as well as the means of transmitting the disease and the

means of slowing the disease?

Mr. NATSIOS. The understanding of the disease, the existence of

the disease, and the risk generally is very high in Africa. It is perhaps well over 90 percent. If you did a survey of the population,

have you heard of this disease and do you know what it does to

you in a generic sense, the answer is virtually the entire adult population in many countries do. The social marketing has been very

effective. When the heads of state begin campaigns on this, they do

not just make one speech. They make repeated speeches. They go

to the countryside. They use radio. They use newspapers and posters and all this.

The problem is—and it is the same problem in the United

States—whether you yourself are at risk. And this is the problem

with teenagers here in the United States where the kids will say,

yes, I know drunk driving is a problem, but it does not affect me

45

and I am not personally at risk. That is a problem with teenagers

everywhere in the world in particular. So, the understanding of the

risk that a person has of getting is not very high.

The CHAIRMAN. Let me ask you. My impression from dealing

with this for some time is that the perception of risk is not as cavalierly viewed in the United States as you made it appear to be. The

perception seems to be less pronounced in other countries. In other

words, it has impacted on behavior here in terms of sexual behavior, not to the extent we want it to, but it has had impact. It is

not like drunk driving, at least the statistics I have seen.

What I am trying to get at is what portion of your efforts to

change behavior—again, please do not read into this that I am suggesting that is the answer, that all we have got to do is just say

no. I am not suggesting that at all. I am trying to get a sense,

though, of how real a risk it is viewed to be, and is it just like it

is in any other—that is, there is no distinction.

Mr. NATSIOS. There is a distinction regionally and there is a distinction on different age groups. There is, for example, a very high

understanding in East Africa. There is less understanding in West

Africa.

The CHAIRMAN. To what do you attribute that?

Mr. NATSIOS. It is a matter of how advanced the disease is, the

religious traditions of the country. Muslim countries have lower

prevalence rates I have to tell you, substantially lower in many

cases. It does not mean it is not present. It means the infection

rates for a country that is 100 percent Muslim is substantially

lower than it is in other parts of the developing world. So, those

value systems, the religious traditions do affect this.

We are seeing success in behavior change in a number of countries where the disease is advanced. I have many Ugandan friends

for many years, and some of them are fairly prominent people in

their country. Several of them have decided not to marry because

they can never be sure that their marital partner would not be infected because the infection rates are so high. It is a tragedy because they would like to marry, but these are some prominent people who have actually said we will be celibate our entire lives because of the extent of the disease. I am sure if the same level of

disease spread took place in the United States, people would make

the same judgment in the United States. It is a matter of survival.

It is changing people’s behavior, I have to tell you, without even

our program, because when you have a certain number of deaths

in a village—in South Africa now in some areas, they are burying

people in the same grave on top of each other. They are layering

them because there is no room left in the graveyards. One NGO I

was talking to in South Africa where I visited one of the clinics was

telling me that they will have in some villages funerals from 6:00

in the morning till 6:00 at night on the weekends continuously all

day long for what is happening. Now, that does have an effect on

the population. People see what is happening. They understand it.

The problem is when it reaches that level, then it is too late, obviously, in many cases to stem the spread of the disease. So, our

job is to prevent it from spreading so that eventuality does not take

place.

The CHAIRMAN. Do you want to make a comment?

46

Mr. ALLEN. I was just going to comment that I think that the

other component to that is political leadership. I think that you will

see the level of awareness of the program closely attributed to political leadership. Countries like Uganda, Senegal, Malawi, countries that have taken a very aggressive stand from the very highest

ranks of government, have been very successful in addressing the

low-hanging fruit, those areas of mother-to-child transmission, securing the blood supply. I think that we have seen, through those

leaders, the ability to get a message out. I think that is where we

have to engage across the spectrum the political leadership as well

in this debate and discussion to begin to educate the public about

how the disease is contracted and how one can prevent from contracting it.

The CHAIRMAN. Senator Feingold.

Senator FEINGOLD. Thank you, Mr. Chairman.

I understand there was some very useful discussion of the Global

Fund after I left, and I will certainly review the transcript with interest. I had indicated that I feel we do need to dedicate more resources to supporting the Global Fund, but I also do strongly agree

with the statements that were made in my absence about the importance of a diversified approach, whether it be bilateral or multilateral mechanisms, and it is especially true if those efforts are

well coordinated.

I think there is no doubt that the United States is a leader in

the donor community when it comes to the fight against AIDS. You

just mentioned Senegal. I saw that last February. In part, the efforts of USAID and others have led to a terrific program and success of bringing together seemingly all elements of society in a very

positive effort in this regard.

But it is precisely for that reason that I am concerned about the

fund. I think U.S. leadership is going to be required to actually

make the fund the strong tool in our arsenal that it has to be.

Mr. Chairman, I am just going to leave it at that. I will have an

opportunity tomorrow in the hearing that you have urged me to

chair to explore this with some of your colleagues. I just want to

thank the panel for all your effort and time.

Thank you, Mr. Chairman.

The CHAIRMAN. Thank you.

Before the panel departs, I had contemplated today having in the

panel of Government witnesses the CIA, as well as the Defense Department, which I may yet do. But I will not take the time now,

but the national intelligence estimate produced by the Central Intelligence Agency entitled A Global Infectious Disease Threat and

its Implications for the United States, the January 2000 report, has

a pretty sobering estimate. Actually it is more pessimistic than

what was communicated here today. But the point is that they

reached several conclusions, one of which is that this epidemic will

challenge democratic development and transitions and possibly contribute to humanitarian emergencies and civil conflicts in the

world. The Defense Department rates this as a greater concern

than an attack from an ICBM, for example, in terms of their interests.

So, this is not merely—it need only be the humanitarian catastrophe that it is producing, but our security agencies are saying

47

that the cost is not only in school teachers, for example, and doctors and people who run the country, but it is among officers of mobilized militaries in sub-Saharan Africa, and increasingly among

those states, which I will not name, that have the possibility of

being categorized as rogue states.

So, this is a multi-faceted dilemma that the world faces and the

U.S. faces that goes beyond what we tend to only think—not you

all, but when we talk about AIDS and we think of it, as we should,

in terms of the humanitarian catastrophe, that it has so many implications, including national security implications, which I think

warrants us paying even more attention. Through the leadership of

all of you and the agencies you represent in the administration, I

think we are on the right track here.

Yes.

Ms. DOBRIANSKY. Mr. Chairman, if I may just make a comment

on that. Before taking this position, I had seen a product of the National Intelligence Council, which was a precursor to the one you

are citing, which was on global trends 2015. It addresses a range

of global issues, citing that if they are not dealt with, that they will

cause conflict and instability in the future. And then the report

that you mentioned was singled out on infectious diseases.

I have to say we have at the Department, through the Bureau

of Intelligence and Research, held a number of conferences which

have brought in both the public sector, different parts of the public

sector including DOD and other agencies, and the private sector,

to discuss not only the humanitarian ramifications but as you

pointed out, the security considerations.

Also, the Council on Foreign Relations published a report which

concluded that the spread of HIV/AIDS and infectious diseases is

a security threat and one that the U.S. Government and the world

at large must address because it affects us all.

The CHAIRMAN. The International Crisis Group issued a report

on the 19th of June of 2001 which reached several conclusions. I

will just read part of one and let you go.

On page 21 of the report, it says, ‘‘Anything that weakens a

state, threatens its military, but also its institutions may create an

environment in which states pose outside aggressors a more tempting target. When major powers are weakened, the effect is less likely to present itself as an invasion in war, but instead increase turbulence and minor violence in the international system. The larger

the country, the larger the potential to stabilize an impact in the

international arena. What happens in Russia, India, China, with

huge populations, large militaries, historic rivalries matters a great

deal elsewhere.’’ And this goes on.

So, I just hope those who are listening to this hearing from the

public at large who think maybe we are spending too much time

and energy focusing on, as not many, but some say, the problems

in other parts of the world understand that this is our problem.

This is our problem.

I thank you all very, very much. I appreciate your consideration

and your time and your patience in the way this has been running.

So, thank you.

By the way, we will, with your permission, probably have some

questions submitted to you, if we may, in writing.

48

[The questions referred to and the answers submitted thereto,

follow:]

RESPONSES TO ADDITIONAL QUESTIONS SUBMITTED FOR THE RECORD BY THE

COMMITTEE TO UNDER SECRETARY OF STATE PAULA DOBRIANSKY

A recent article appearing in The Lancet raised concerns over the capacity of potential African grant recipients to meet the standards the Global

Fund has set for the preparation of applications and the implementation of

Fund-supported activities, including project monitoring. The authors suggest that the Fund’s standards and objectives could pose undue burden on

ministries of health in Africa and lead to early disappointment with the

Fund’s performance.

Question. Would you share with us the requirements for fund applications and

monitoring?

Answer. The Global Fund to Fight AIDS, Tuberculosis and Malaria has established the principle of public-private partnership as a critical aspect of its functioning. This principle is particularly important at the country level, where proposals are developed and implementation will occur. The work of preparing applications can and should be shared among all partners, not only ministries of health.

The Fund requires that proposals be developed and implemented by Country Coordination Mechanisms (CCMs) that include all relevant partners at the country level,

although there is a provision allowing NGOs to submit proposals directly to the

Fund where such partnerships are not possible. These do not have to be new groups.

The intent is to build on already existing coordination mechanisms to develop initial

proposals, and over time to strengthen them. The Fund has been able to learn from

the experiences of others, including the Global Alliance for Vaccines and Immunizations (GAVI), the subject of The Lancet article.

While one goal of the application process is to be as simple as possible, there must

be sufficient information to ensure that only high-quality projects are funded. There

is also a need to ensure that appropriate financial and program accountability structures are in place at the country level.

Each proposal will include a monitoring and evaluation plan. The Fund itself is

establishing its own monitoring and evaluation framework at the global level. To the

extent possible, the Fund will build upon monitoring and evaluation frameworks established by other donor organizations and multilateral agencies such as the World

Health Organization. It is expected that Fund partners such as USAID and HHS

at the country level will contribute to the process of establishing, strengthening, and

supporting data collection systems at the country level.

The details for monitoring and evaluation are currently being discussed in an

international working group that includes representation from HHS and USAID,

both of which have extensive expertise in monitoring and evaluation. The goal is

to have meaningful measures that not only enable countries to monitor their own

progress, but also allow the donor organizations and countries to assess the impact

of the Fund’s grants portfolio.

Each proposal will also have to demonstrate strong and transparent arrangements

for financial management and control.

Question. To what extent do you share the concerns raised in the article?

Answer. There is broad recognition among those involved in creating the Fund

that many prospective recipients have capacity constraints. That is why USAID,

HHS, other donor countries and multilateral organizations have committed to providing technical assistance, as appropriate and upon request, to help country partnerships prepare proposals, implement projects, and conduct monitoring and evaluation. These partners can help the country partnerships identify existing programs

and resource availability, as well as programmatic and resource gaps that the Fund

can fill.

The Fund has been established as a public-private partnership and proposals will

come from partnerships, not from governments, although governments are expected

to be important partners in most instances. The Fund was established based on the

premise that no one sector or institution has the capability alone to deal with the

problems posed by AIDS, tuberculosis and malaria, and that partnerships are,

therefore, vital. However, the Fund also recognizes that building country capacity

to implement and monitor programs is an appropriate area for Fund support. Fund

donor partners, such as USAID and EMS, will continue to emphasize capacity building as part of their bilateral programs.

49

We consider financial accountability and monitoring and evaluation critical to establishing and maintaining credibility and transparency. Meeting these requirements will require some attention and effort on the part of country partnerships,

and should be considered as worthwhile investments. The Fund can help countries

build adequate systems for health data and fiscal accounting that will not only assist in monitoring the progress of the Fund, but also will aid the countries in improving their health care infrastructure.

Question. What role do you see the Agency for International Development, the

Center for Disease Control and Prevention, or other U.S. agencies in helping African

applicants meet the standards the Fund has set? What assistance, if any, has already been provided?

Answer. It is not only African applicants who will need assistance in meeting the

reasonable and prudent standards set by the Fund. State and USAID have sent a

series of cables to the field to brief our embassies and missions overseas on the

Fund and to encourage them to work with Country Coordination Mechanisms

(CCMs) to help in the proposal preparation process.

USAID is presently developing a strategy to utilize mechanisms and capacity at

the global and regional levels to provide technical assistance to CCMs for proposal

development, and to ensure that our bilateral support is coordinated with expected

support from the Fund. USAID is also developing a process to mobilize technical assistance resources from a range of its contractors to provide assistance to CCMs at

the country level, to help identify critical gaps and constraints to scaling up successful activities, so that Fund proposals submitted to the Fund can address those gaps

and constraints.

Thus far, HHS, through field staff of the Centers for Disease Control and Prevention (CDC), has been invited to assist with the Global Fund proposal process in six

countries: Botswana, Kenya, Mozambique, Tanzania, Uganda, and Zambia.

• In Botswana, HHS will serve on the MOM’s technical advisory committee for

review of incoming TB proposals and on the National AIDS Coordinating Agency’s technical advisory committee for review of incoming HIV proposals.

• In Kenya, HHS, along with other donor groups, will be given the opportunity

to review the submission.

• At the request of those involved in preparing a proposal, the HHS Global AIDS

Program staff in Mozambique has provided input.

• HHS Global AIDS Program staff in Tanzania will provide technical input on

that country’s proposal.

• HHS staff in Uganda has been invited to meetings at the Uganda AIDS Commission.

• In Zambia, HHS Global AIDS Program staff has worked on the TB portion of

the proposal.

Furthermore, staff at HHS and USAID has been involved in the various working

groups established by the Fund to develop guidelines for monitoring and evaluation

and other technical matters. Once these initial consultations are complete, we expect that staff will continue to be involved once grants have been made, in assisting

the countries directly, when requested.

In providing support on proposals, we cannot, of course, guarantee that specific

requests will receive funding. Our goal is to provide advice and expertise not only

in the proposal writing stage but with the actual work that is being suggested to

ensure that it fills gaps in current programs.

Question. What measures for evaluating the performance of grant recipients is the

United States advocating?

Answer. Program and financial accountability have been identified by the Fund

as critical components of proposals to be considered for funding. The Fund has created a working group to develop a monitoring and evaluation strategy and procedures that can be further developed and strengthened over time. This group will

also look into the possibility of making funding available in tranches, with continued

funding of projects based on achievement of agreed milestones and targets. The U.S.

intention is to ensure that these milestones and targets are both measurable and

meaningful. A panel of experts from HHS and USAID is helping to determine what

such indicators might be and to develop appropriate mechanisms and procedures to

insure that valid data on these indicators can be provided. While demonstrable reductions in some disease or infection rates may take time, we do expect certain

operational milestones, such as increased coverage with proven effective interventions, to be met before continued funding is made available.

50

Establishing fair and realistic targets and indicators, neither too high nor too low,

is extremely important as the Fund prepares to accept the first round of proposals.

One of the early recommendations of the United States was to have each application

reviewed from the perspective of monitoring and evaluation to ensure the soundness

of applicants’ plans and their ability to utilize existing or planned monitoring and

evaluation systems and indicators.

The United States is also insisting that appropriate fiscal controls be in place,

both at the country and global levels to ensure that funds are used for the purposes

intended.

Question. To what extent are these measures likely to be effective?

Answer. The Global Fund is a new mechanism to provide additional funding for

the scale-up of programs at the country level. It has been developed very rapidly,

and is about to enter an operational phase in which it may take several years before

we see meaningful changes at the global level. Nonetheless, the Fund must be sufficiently flexible to learn from lessons learned both by others and itself and to change

procedures to help ensure better performance over time.

Experience gained through the review and initial implementation of the first

grants that will be approved in April will be the basis of future modifications to improve capacity in this critical area. The United States Government (USG), especially

USAID and HHS, have particularly good experience at the country level in the

areas of monitoring and evaluation. The USG will play a leadership role on the

monitoring and evaluation working group, and should be able to offer specific assistance in proposal development and strengthening local capacity to improve surveillance and monitoring systems.

Question. What burdens, if any, do they impose on health ministries, other government agencies, and non-governmental organizations in the recipient countries?

Answer. The Fund has tried to strike a reasonable balance between simplicity and

accountability, but it will be dealing with large grants. It is not unreasonable to ensure that recipients are able to use such funds for the purposes for which they are

intended and to reach the greatest number of people in a safe and efficient manner.

The application process is the first demonstration of the capacity of recipients to fulfill their commitments. The intent, wherever possible, is to use existing plans and

processes as the basis for proposals and for monitoring and evaluation. However,

many country partnerships, with the aid of bilateral and multilateral partners, will

have to engage in planning processes and write new proposals because they have

not done the work previously. There is no other way to ensure that Fund proposals

fit into national priorities, are feasible, and scientifically and technically appropriate. The Fund will work to keep the burden as low as reasonably feasible, within

the limits of prudent grant-making.

It is especially important to use the additional resources and attention coming

through the Global Fund to identify weaknesses and assist country personnel to improve surveillance capacity to monitor the progress of the epidemics and contribute

to tracking impact of Global Fund-supported programs. The Fund will benefit from

work already developed by its partners on monitoring and indicators. It expects to

be able to use procedures and systems already in place, and in many cases supported by other Fund partners to meet the requirements of a rigorous monitoring

and evaluation system.

Question. A couple of years ago, this Committee [the Senate Committee on Foreign Relations] and the Congress made a strong commitment to relieve the international debts of the poorest countries. And yet, it is my understanding that many

of these countries still pay more in debt service to multilateral creditors than on

health care.

Answer. The Administration greatly appreciates—and strongly endorses—the support the Congress has provided for debt relief under the Heavily Indebted Poor

Countries (HIPC) Initiative. The HIPC Initiative greatly increases the prospects for

economic and social development in beneficiary countries by allowing them to redirect into social sector spending funds that would have been due for debt service.

A recent IMF/IDA report, ‘‘The Impact of Debt Reduction under the HIPC Initiative on External Debt Service and Social Expenditures,’’ provides information on initial results for the first 24 HIPC countries to reach their decision points. After HIPC

implementation, debt service due has fallen sharply from 29 percent of government

revenue in 1998 to an expected 11 percent in 2003. The report also notes that social

sector spending rises from 33 percent of government revenue in 1999 to 39 percent

in 2002, suggesting the desired redirection of spending is taking place. The above

data would suggest that the HIPC Initiative has caused a broad and pronounced

51

shift from all categories of external debt service (not just multilateral) to social sector spending.

Typically, the health and education sectors receive special emphasis in social sector spending. Examples of programs in the health sector that HIPC savings will

help fund include:

• Mozambique has committed to use debt service savings to expand the stock of

basic medicines in government health clinics.

• Uganda will use enhanced HIPC relief to expand the country’s successful HIV/

AIDS awareness programs.

• Madagascar intends to use about 20% of its HIPC savings for programs in the

health sector, to include immunization programs, an anti-HIV/AIDS campaign,

the recruitment of medical personnel, and the supply of drugs and medicines. •

• In Cameroon, the U.S. Embassy reports that the 2001–02 budget breaks out $49.3 million of HIPC debt relief savings, of which $9.1 million will be spent

on health programs, with an emphasis on HIV/AIDS and malaria. 1,000 public

health workers will be recruited.

Yet, the success of the HIPC Initiative and broader development assistance ultimately depends not only on the assistance provided, but even more importantly on

country efforts to undertake the necessary economic and social reforms that create

the basis for sustained economic growth. In this regard, quality and effectiveness

of spending in the health sector will be as important as amounts of spending.

Question. Is the level of debt relief currently provided sustainable over the long

term, and sufficient to enable highly indebted countries to deal with the AIDS crisis

and meet their critical development needs?

Answer. The HIPC Initiative will greatly enhance the prospects of debt sustainability through a substantial reduction in the HIPC countries’ debt. The World Bank

and IMF estimate that for the first 24 countries, HIPC debt relief will total more

than $36 billion over time. However, given that these countries face steep development challenges and are highly vulnerable to external shocks, it will be important

to focus on maintaining long-term debt sustainability. Most importantly, this will

require sound economic policies in HIPC countries that create the basis for sustained economic growth. In addition, strong debt management, including prudent

borrowing policies, will play an important role. Finally, creditors need to ensure that

new financial assistance is provided on appropriate terms, including through increased use of grants.

With regard to the AIDS pandemic and the fight against other infectious diseases,

the U.S. and other donors have recognized the need for additional resources above

and beyond those freed up by the HIPC Initiative. The Administration’s 2003 budget

request proposes total bilateral and multilateral assistance for HIV/AIDS, TB and

malaria programs in developing countries of nearly $1.2 billion, up from $1 billion

in 2002. This $1.2 billion includes $200 million for the Global Fund to Fight AIDS,

Tuberculosis and Malaria, raising the overall U.S. pledge to $500 million. The U.S.

commitments in FY 2002 and FY 2003 will account for more than a third of estimated international donor funds. USAID is the single largest bilateral donor.

Question. Are countries that are benefiting from debt relief savings able to channel a substantial amount into the health sectors of their national budgets? If not,

why not, and is there some assistance we could be providing to help them do so?

Answer. Although it is early in the HIPC process to provide an authoritative response based on how HIPC countries have actually spent their money, the IDA/IMF

reports 2001 and 2002 budgets have a significantly higher level of social sector expenditure in the HIPC countries that have begun to benefit from debt reduction. In

the 24 countries that have reached their Enhanced HIPC decision points, the report

indicates that social sector spending rose from $5.1 billion in 2000 to $6.0 billion

in 2001, and is projected to rise to $6.9 billion in 2002.

Question. You mentioned in your testimony that Secretary Powell created a new

Deputy Assistant Secretary for International Health and Science, a role to be filled

by Dr. Jack Chow. Dr. Chow is also to serve as the special representative of the

Secretary of State for HIV/AIDS with the rank of Ambassador, subject to the Senate’s confirmation.

What effect will the creation of this office have on HIV/AIDS policy?

Answer. By establishing the post of Deputy Assistant Secretary for International

Health and Science, the State Department effectively raised the profile of health

issues on the foreign policy agenda. Confirmation of Dr. Chow as the special repVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00055 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
52

resentative of the Secretary of State for HIV/AIDS with the rank of Ambassador will

signal to our contacts around the world the importance the United States attaches

to health issues.

As Deputy Assistant Secretary, Dr. Chow serves as the primary focal point in the

USG on international issues related to HIV/AIDS and other infectious diseases, especially tuberculosis and malaria. He represents the United States in international

negotiations.

If confirmed as special representative, Dr. Chow will work with presidential envoys and senior representatives from other nations to ensure an international response to HIV/AIDS. He will work to strengthen the Department’s capabilities and

to promote inter-agency coordination and cooperation on global HIV/AIDS.

Question. The President’s budget request for FY 2003 includes $2 million in for

[sic] the State Department’s Foreign Military Financing program to ‘‘complement’’

a Department of Defense program that is aimed at educating African militaries

about HIV/AIDS. $2 million is not a lot of money. Do you know how much funding

did the President ask for in the FY 2003 Department of Defense budget for the program.

Answer. Resources for DoD’s Africa Initiative in Military Medicine (AIMM), which

seeks to provide training and education on HIV/AIDS for sub-Saharan militaries,

total $10 million in FY2001 and $14 million in FY2002. It is my understanding that

DoD’s FY 2003 budget request does not include funding for AIMM.

Question. What activities will the State Department engage in that are complementary to the Department of Defense program?

Answer. The fight against HIV/AIDS and other maladies in Africa requires a

multi-agency effort. HIV/AIDS and other diseases have weakened and reduced the

security capacity of Africa’s militaries. DoD’s Africa Initiative in Military Medicine

(AIMM) seeks to provide training and education on HIV/AIDS for sub-Saharan militaries. It is my understanding that in FY 2002 the Department of Defense was allocated $14 million for AIMM.

Subject to Congressional approval, the Department of State Foreign Military Financing program plans to allocate $2 million of FY 2003 FMF funds to purchase

equipment such as computers and resource management software for creating and

maintaining databases, laboratory and medical supplies, testing equipment, and

rapid test field kits. This equipment will both complement and sustain the training

initiative in African partner countries.

Question. According to a recent GAO report (December, 2001) the United Nations

does not know how many peacekeepers have HIV/AIDS because it opposes mandatory HIV testing before, during or after deployment to a peacekeeping mission. With

all that we now know, with all the evidence we have that peacekeepers, like other

military personnel, are likely to engage in behaviors such as unsafe sexual practices

that increase the risk of contracting and spreading HIV, what is the rationale for

continuing the policy of NOT testing peacekeepers?

Answer. UN policy on HIV testing in the context of peacekeeping operations is

under review. In November 2001, an expert panel on HIV Testing in UN Peacekeeping Operations met in Bangkok, Thailand. Participants included UNAIDS, the

UN’s Department of Peacekeeping Operations (DPKO), military officials from peacekeeping contributing nations, and legal experts. In addition, a pilot project funded

by Norway and Denmark is being developed to begin a further assessment of

UNAIDS’s prevention strategies for peacekeepers

The DPKO has designed its current HIV/AIDS policy to comply with the wishes

of its member states, which have divergent views on HIV testing. The UN in general

and the DPKO specifically are also conscious to avoid policies that might increase

discrimination against HIV-positive individuals.

The UN’s policy on HIV testing of peacekeepers is largely determined by its contributing countries. For instance, some countries do not screen their military personnel for HIV. Others may test their forces but do not share this information publicly, considering such information sensitive. There is further concern among other

countries that mandatory testing could be used for political decisions on the suitability of certain national forces to serve as peacekeepers.

This position is also based on human rights concerns. The UN has resisted screening for HIV on the grounds that it could increase discrimination against and stigmatization of those infected with the virus. In addition, the UN’s personnel policy

states that the only appropriate medical criterion is fitness to work. Accordingly,

those not exhibiting clinical signs of AIDS are not precluded from peacekeeping

service.

53

UN Security Council Resolution 1308 (July 2000) encourages UN agencies to take

action with UN member states to develop strategies to mitigate the spread of HIV/

AIDS in peacekeeping missions. These efforts have focused on three interventions:

the development and use of an HIV/AIDS awareness card; training of troops in HIV/

AIDS prevention; and the distribution of condoms to peacekeepers.

DPKO recommends that countries contributing to UN operations should not send

HIV-positive individuals on peacekeeping missions. However, UN policy opposes

mandatory testing and countries retain control over their forces, so DPKO cannot

force countries to test or keep data on HIV prevalence.

Our next witness will be Dr. Peter Piot. He is the Executive Director of the joint United Nations Programme on HIV/AIDS and is

Assistant Secretary-General of the United Nations as of December

way back in 1994. He has done a great deal of work in this area.

We are flattered he would take the time to be here, and we welcome his testimony. Doctor?

STATEMENT OF DR. PETER PIOT, EXECUTIVE DIRECTOR,

UNAIDS, GENEVA, SWITZERLAND

Dr. PIOT. Thank you, Mr. Chairman, Senator Frist, Senator Feingold, ladies and gentlemen. It is up to me to thank you for the opportunity to testify this morning, and I would like to applaud you

for your commitment and also for the focus on the global AIDS epidemic.

I am here today on behalf of the UN system organizations, in

particular those AIDS agencies who make up UNAIDS, the Joint

United Nations Programme on HIV/AIDS.

Twenty years since the world became first aware AIDS, three

things have become clear. First, that we are facing the most devastating epidemic in human history. Second, that for all the devastation it has already caused, the AIDS epidemic is still in its early

phases. A sobering thought. And third, that we are in a position

to bring the epidemic under control. Today, I would like to focus

on this third lesson, that we are prepared to succeed.

Mr. Chairman, I believe that for the first time in the short history of this epidemic, the world is in a position to translate the few

local and national examples of success into a truly global movement and also a global success.

So, what is different now from 5 years ago?

One, manifestly greater political momentum to address the AIDS

epidemic. It is really everywhere and not least in this country and

right here on Capitol Hill. You will hear Secretary-General Kofi

Annan this afternoon. He has made the fight against AIDS his personal priority. Five years ago, it was often difficult to persuade

even health ministers that they ought to take AIDS seriously.

Today when global leaders meet, AIDS is on their agenda from the

G–7 to the World Economic Forum (at its meeting last week, for

example), and especially among African heads of state.

Second, there is now a clear set of global priorities in the fight

against AIDS. The series of benchmark targets adopted by all the

world’s countries at the Special Session on AIDS of the UN General

Assembly last June in New York provide a common platform for accountability, and we have clear international consensus on a global

strategy which stresses young people as a priority for action on

AIDS and recognizes that prevention and treatment and care are

integral parts of an effective response.

54

The third advance is that we have empirical evidence that action

around such a strategy actually results in success. Very importantly, it results in fewer people becoming infected. No longer only

Uganda and Thailand and Senegal, but also a country like Cambodia—after decades of genocide and civil war, it has less infections

today than 5 years ago. Zambia, Tanzania, Brazil and others are

also examples of success.

The fourth advance from 5 years ago is in the new realism about

the resources required to effectively tackle AIDS in the developing

world. As we heard this morning, roughly $10 billion annually is

needed for a comprehensive AIDS response.

Mr. Chairman, I will now focus on two issues related to achieving success. The first one is on the question of the degree of program readiness in developing countries and second is on the resource gap. I will then conclude with discussing some opportunities

and challenges for spending resources wisely and effectively.

First, we should remind ourselves that today we need to plan for

success, and wherever effective AIDS responses are found, there

are five key principles at work. There is leadership at all levels,

mobilization of broad coalitions and good coordination. Overcoming

stigma is one of the major obstacles to prevention and care. Fourth,

responding at the scale commensurate with the epidemic. Finally,

applying strategies based on good science, whether that is biomedical science or political science.

All this requires resources, not only dollars, but also capacity,

people, systems, institutions. And that brings me then to the first

broad issue.

Do developing countries, developing societies have the capacity to

program greatly increased funds to combat AIDS in their communities? We have been looking into this crucial question. We have

been looking into this crucial question as part of an ongoing

UNAIDS assessment of the current status of AIDS programs in 114

low- and middle-income countries.

We used five core indicators of AIDS readiness: national AIDS

plans, the capacity to operationalize the plan, costings of the plan,

a monitoring and evaluation strategy, and mechanisms that can

achieve coordination among governments, nongovernment actors,

the UN system, and bilateral donors.

Across the globe, of 114 countries there are 24 countries assessed

where all the elements of comprehensive AIDS programming are

already in place. At the other extreme there are eight countries

which are yet to develop any of the elements of readiness. Most are

in the middle range.

These results are encouraging, but at the same time they also

identified some generic weaknesses, such as insufficient monitoring

and evaluation capacity. Above all, they tell us that unless we invest equally in people, systems, and institutions, as much as in activities and interventions, we have less chance of getting the dollars to do their work.

It also tells me, also as Mr. Natsios alluded to, that it is time

for some out-of-the-box thinking, meaning for me outside of the

public health system, outside the health services when it comes to

tackling AIDS. Particularly in many African countries, the capacity

of these health systems today is probably lower than it was at the

55

beginning of the AIDS epidemic for a variety of reasons, including

because of AIDS itself which is killing the doctors and the nurses.

So, let our AIDS programs go to where the capacity is, business

and unions, churches and mosques, schools and sports.

Mr. Chairman, let me now turn to the issue that is on

everybody’s mind in this room apparently and that is the other side

of the resources. That is the dollars. The needs are now well documented. They were mentioned many times this morning. But where

are we today with the money available?

The total available this year, we estimate, is going to be roughly about $2 billion in terms of international resources, which by the

way is less than the NIH budget for AIDS research, as I heard this

morning.

The good news and real progress is that the Global Fund represents a 50 percent increase this year in currently available international funds for AIDS, and it has really generated additional

money not only in this country but also from the European and

Japanese side. That in itself I think is already a proven valueadded of this Global Fund.

As Secretary Thompson mentioned, less than a year ago, UN

Secretary-General Kofi Annan called for a war chest at an OAU

Summit on AIDS in Abuja. And we had already the first meeting

of the board of directors, and most probably in April, the first

grants will be given, and that will be less than a year after the

first pledge to the fund by President Bush.

But let me be clear, Mr. Chairman, since you raised it yourself as well. The Secretary-General, when he was mentioning $7 billion

to $10 billion, said that this represents the current need of programmable AIDS funds in the world. He never meant to say that

all this money should go through one single mechanism, the Global

Fund.

Since Secretaries Thompson and Dobriansky gave a very accurate description of where we are with the Global Fund, I will not

repeat it. But I would say that the comparative advantage of this

newest actor must be in its ability to focus new resources, additional resources, rapidly and directly, on the programs with the

best chance of success in the countries with the greatest needs. I

think what has come out of the fund negotiations is very close to

what was called for in the original legislation in this house.

I feel that this is a good and very promising start, but Mr. Chairman, allow me to focus now on the resources gap today and tomorrow.

Our estimates take into account what we believe the growing

needs and growing program capacity will be in the near future. The

Global Fund represents one-third of currently available international resources for AIDS; it accounts for about 16 percent of the

total need.

The gap between current expenditure and total needs is so large,

that moving immediately to the $10 billion of expenditure is impractical. Instead, we need to envisage a route to a comprehensive

response where the available funds progressively increase over the

next 4 years. If today’s expenditure on AIDS were to be maintained

only, next year’s funding gap will be greater than $2 billion. By

2005, it will be about $7 billion.

56

But if we build on current activity and make a reasonable estimate of where it can be scaled up, then for each of the next 4

years, expenditures need to be increased by roughly 50 percent.

This should not only happen in terms of the Global Fund to Fight

AIDS, TB, and Malaria, but in terms of all resources that are there

to fund AIDS programs, including resources of the governments of

the countries that are affected. Some large, middle income countries have already started to spend significant amounts of money

on AIDS. I am thinking of Brazil, India, South Africa, and incidentally, Brazil and South Africa at the board meeting indicated that

they will not seek funding from the Global Fund on AIDS, TB, and

malaria.

So, Mr. Chairman, the fight against AIDS is a race and so far

it is the virus that has been winning. There is no doubt about that.

But we are now in a position to make a leap forward, a leap that

for the first time will put us ahead of HIV.

I would be kidding myself, of course, and all of you if I said that

this task was going to be a very easy one. There are huge challenges, and collectively we have to turn thousands of really effective AIDS programs and activities around the world into hundreds

of thousands, reaching all nations. We have got to coordinate all

the players in the AIDS response—very important now with increasing resources. We have got to unblock the resource pipelines

so resources get to communities effectively. We have got to meet

the challenge to be led by science and evidence, and we have got

to put in place strong mechanisms of programmatic and financial

accountability.

You, the U.S., have already proved yourself willing to take a

leadership role and make the required leap forward. We would

strongly encourage you to continue in that leadership role, because

I know that it is contagious—in the good sense of the word—to

other countries. And I look forward to our continued partnership in

meeting this great challenge. Thank you.

[The prepared statement of Dr. Piot follows:]

PREPARED STATEMENT OF DR. PETER PIOT, EXECUTIVE DIRECTOR, UNAIDS

Mr. Chairman, distinguished members of the committee, ladies and gentlemen.

I thank you for the opportunity to testify this morning, and I applaud you for your

focus on the global AIDS epidemic.

I am here today on behalf of the UN System organisations responding to the global epidemic, and in particular the eight UN agencies whose collective efforts on

AIDS make up UNAIDS, namely UNICEF, UNESCO, ILO, the United Nations Development Programme, UNFPA, UNDCP, the World Health Organization and the

World Bank.

AIDS IS DIFFERENT

And Mr. Chairman, I am here today to tell you that the AIDS epidemic is different from any other epidemic the world has faced, and as such, requires a response from the global community that is broader and deeper than has ever before

been mobilized against a disease.

Twenty years since the world first became aware of AIDS three things have become clear:

• that humanity is facing the most devastating epidemic in human history, the

impact of which threatens development and prosperity in major regions of the

world.

• that for all the devastation it has already caused, the AIDS epidemic is still in

its early stages; and

• that we are in a position to bring the epidemic under control.

57

The first twenty years in the history of an epidemic is only the blink of an eye.

The other communicable diseases that ravage many parts of the world have been

known for many centuries. Their patterns of spread have become well-established

and predictable.

Mr. Chairman, committee members, AIDS is unlike any other epidemic that we

have faced:

• It affects every strata of society—wealth is no protection against the virus;

• Young adults are its biggest target—so it kills people just when they are in the

most productive—and reproductive—phases of their lives;

• It has far-reaching ripple effects, on the economy, on the family and for the generation of children left without parents;

• It remains surrounded by taboo and stigma—still a huge barrier to effective responses.

• It spreads silently, so millions can be infected with HIV in a population before

the impact in illness and death becomes apparent.

This silent spread and slow impact of AIDS have meant that the threat it poses

has been consistently underestimated. For a moment, let us compare it to the much

feared Ebola, a virus I have had first-hand experience of, dating back to when I was

a member of the team that investigated the first known epidemic of Ebola virus infection in 1976 in then-Zaire.

Ebola spreads rapidly and causes illness instantly, so there is never any doubt

about the need for a rapid and comprehensive response. Today, when Ebola breaks

out anywhere, action teams are dispatched without delay. The immediate and

present danger it represents is readily recognized and the international community

immediately mounts an appropriate response to halt the new epidemic—and Ebola

has caused probably no more than 1000 deaths in total.

Now, let us imagine a much smarter virus than Ebola. A virus just as deadly,

but one capable of creeping silently through whole populations before it revealed

itself. A virus whose casualties from its local epidemics are not measured in the

hundreds, but in the hundreds of thousands. A virus that kills slowly, and painfully,

and generally only after stigmatizing and pauperizing the entire family of an infected person.

It is difficult to imagine a smarter, more devastating virus than the subject of this

hearing, the virus that causes AIDS. And it is equally difficult to imagine a world

unwilling to mobilize to slow the spread and eventually contain this virus. All the

more so, given what we know about it, how long we have seen it coming, and where

we can now see it going.

THE STATE OF THE GLOBAL EPIDEMIC

More than 60 million people worldwide have been infected with the virus—nearly

double the population of California. Since the epidemic’s start, twenty million of the

sixty million people infected with HIV have died—a number equivalent to the populations of Texas or New York State.

HIV/AIDS is now by a large margin the leading cause of death in sub-Saharan

Africa and the fourth-biggest global killer. Life expectancy in sub-Saharan Africa is

now 47 years, when it would have been 62 years without AIDS. In 2001 alone, an

estimated 5 million people became infected with HIV, and half of them were young

people between the ages of 15 and 24. There were an estimated 800,000 children

under 15—mainly infants—infected with HIV in 2001, and 580,000 child deaths as

a result of AIDS.

Sub-Saharan Africa is the region of the world where the epidemic has been worst

and where its impact increasingly threatens the stability of whole societies.

Average prevalence in sub-Saharan Africa is 8.8 per cent in the adult population

(15-49 years old). There are seven countries, all in the southern cone of Africa,

where more than twenty per cent of adults are infected with HIV, and a further

nine countries where infection rates exceed ten per cent.

We still do not know what is the upper limit for the extent of HIV spread in a

population. Botswana is the country with the highest HIV rate to date with 36 per

cent of adults infected. It is followed by Swaziland, Zimbabwe and Lesotho all between 24 and 25 per cent.

While the scale and impact of AIDS in sub-Saharan Africa is the worst in the

world, HIV is a rapidly expanding problem in other regions.

HIV/AIDS is growing fastest in the countries of the former Soviet Union. There

are a million cases in the region, and at least 250,000 new HIV infections in the

past year—most of them in the Russian Federation. Ukraine has the highest prevalence with nearly 1% of the adult population living with HIV.

58

In Asia, China and India currently have relatively small overall prevalence, but

given their huge populations, within each there are large numbers of people and locally high proportions that are infected with HIV. For example, the Indian states

of Maharashtra, Andhra Pradesh and Tamil Nadu, each with over fifty million people, have HIV rates measured in pregnant women above three per cent, over four

times the national average. In China, we have estimated that concerted action

taken now will be able to avert ten million new HIV infections over the coming decade.

Adjacent to the U.S. mainland, the Caribbean is, next to Africa, the second-most

affected region in the world. In a number of countries in the Caribbean and Central

America more than two per cent of the population is HIV infected and adult HIV

prevalence has risen to over 4% in Haiti and the Bahamas.

Nor can we declare HIV a problem that is over in the U.S., western European,

and other wealthy countries—the rate of new infections in the U.S. and Western Europe has not been significantly reduced in the last decade. In the course of 2001,

an estimated 30,000 adults and children became infected with HIV in Western Europe and 45,000 in North America, taking the total numbers living with HIV in

these regions combined to 1.5 million. In these countries the face of the epidemic

has changed, and it is among the poorer, ethnic minority and immigrant populations

that the numbers infected with HIV are growing fastest. Ironically, access to more

effective HIV treatment may also be associated with rises in unsafe sex among some

of the populations that historically have shown the greatest level of behaviour

change, such as gay men.

THE IMPACT OF AIDS: EVERY SECTOR IS AFFECTED

Mr. Chairman, distinguished committee members, AIDS is currently one of the

greatest threats to global development and stability. It is a long-term humanitarian

crisis of unprecedented proportions—the death and misery it has caused in the past

twenty years dwarfs all of the natural disasters that have occurred in that time

combined. The HIV epidemic has not only disrupted many millions of individual and

family lives, it has threatened the stability of entire societies.

Economic Impact

In the worst affected countries, AIDS has a major impact on business productivity, on livelihoods and the supply of food, and on professionals: from doctors

through to police forces. For example, in Kenya, AIDS accounts for 75 per cent of

all deaths in the police force over the past two years. AIDS not only affects the poor,

but also the educated and skilled. In South Africa, for example, ING Barings Bank

projects that one-third of the semi-skilled and unskilled workforce will be HIV-positive by 2005, 23 per cent of the skilled workforce and 13 per cent of the highly

skilled workforce. In the mining industry throughout Africa there is now an acute

problem in replacing skilled mine workers lost to AIDS. And in Zambia, nearly two

thirds of deaths among managers have been found to be attributable to AIDS, a

higher proportion than among middle-ranking workers.

Consequently, AIDS has a direct impact on rates of economic growth in the most

affected developing countries. There is a direct relationship between the extent of

HIV prevalence and the severity of negative growth in GDP. When the rate of HIV

in a population reaches 5 per cent, per capita GDP can be expected to decline by

0.4 per cent a year. And when HIV reaches 15 per cent, a country can expect a one

percentage annual drop in GDP.

The cumulative impact of HIV on the total size of economies is even greater. By

the beginning of the next decade, South Africa, which represents 40 per cent of the

region’s economic output, is facing a real gross domestic product 17 per cent lower

than it would have been without AIDS. Similar studies in the Caribbean suggest

Jamaica and Trinidad and Tobago face a five per cent loss in GDP by 2005 as a

result of AIDS.

In settings where subsistence agriculture predominates, measured economic productivity only scratches the surface of the total impact of HIV on livelihoods. For

example, AIDS hits the long term capacity for agricultural production, as livestock

is often sold to pay funeral expenses, or orphaned children lack the skills to look

after livestock in their care.

Armies are among those most affected by HIV. HIV rates in the armed services

are in many cases two or three times higher than those in the respective civilian

populations. When armies are deployed they spread HIV in the populations where

they are stationed, and when they are demobilized they spread HIV in the towns

and villages to which they return.

59

Human Impact

But measures of per capita GDP in fact underestimate the human impact of

AIDS, as AIDS kills people, not just economic activity. We should reflect on what

it means for a society when 10, 20 or 30 per cent of the population is HIV infected:

• with today’s rates of infection, there is a more than 80 per cent chance that a

fifteen year old boy today in Botswana will eventually die as a result of AIDS;

• nurses and teachers are dying faster than they can be replaced. Last year there

were around a million African schoolchildren who lost their teachers to AIDS.

In Malawi 6 to 8 per cent of the teaching workforce die each year.

The immediate impact of AIDS is felt most acutely in families where one or more

members are HIV infected. In South Africa, households will on average have 13 per

cent less to spend per person by 2010 than they would if there were no HIV epidemic. In Cote d’Ivoire in West Africa, the household impact of HIV/AIDS has been

shown not only to reverse the capacity to accumulate savings, but also to reduce

household consumption. AIDS not only affects income, with lower earning capacity

and productivity, it also generates greater medical, funeral and legal costs, and has

long term impact on the capacity of households to stay together.

This is most manifest in the number of children orphaned by AIDS, which now

totals nearly 14 million. In developing countries, before AIDS around 2 per cent of

children were orphaned, but now in many countries, 10 per cent or more of children

are orphans. The war in Sierra Leone left 12,000 children without families. AIDS

in Sierra Leone has already orphaned five times that number.

A fundamental part of our response to the epidemic must address how families

and communities will cope.

• How many orphaned boys, and particularly girls, will not go to school because

there is no one to pay their school fees, or no one to dress them and get them

out of the house in the morning, or because they have to help grow the food

to feed the remaining family?

• What does it mean for society to have a significant proportion of desocialized

youth?

• How many will end up desperate and easy prey for militias and warlords?

Progress in the global response

Mr. Chairman, distinguished committee members, for too long we have been

transfixed by the toll of the increasing HIV epidemic, unfolding before our eyes.

Now we are shifting our gaze: success is squarely in our sights.

I believe that for the first time in the short history of this epidemic, the world

is in a position to translate local and national examples of success into a truly global

movement against the HIV epidemic. This is a great leap forward from where we

were even a few years ago.

Five major elements define what today gives us the ability to seriously and successfully approach this epidemic on a global scale.

First: there is manifestly greater political momentum dedicated to addressing

AIDS. We have learned that political leadership is required at all levels to marshal

the necessary commitment and resources for the social mobilisation on which the

response must be built.

• The level of political commitment to addressing AIDS has dramatically increased on every continent—and not least in this country, and very importantly,

right here on Capitol Hill.

• Within the United Nations, increasing momentum is being led by the SecretaryGeneral Kofi Annan. His public declaration that the fight against AIDS is his

personal priority has helped to energize the whole of the UN system in its focus

on AIDS, as well as opening doors to key political and business leaders around

the world on this issue.

• In many cases, it has been when Presidents and Prime Ministers have taken

control of the AIDS response that the most rapid advances have been made.

Five years ago, we were challenged just to persuade Health Ministers that they

ought to take AIDS seriously. Now, we find ourselves responding to Presidents

and Prime Ministers throughout Africa, the Caribbean, the Americas, Asia and

Eastern Europe who display deep personal commitment to the fight against

AIDS.

• Some of the most prominent political leadership has been in Africa. For example, two years ago Botswana’s President Mogae declared ‘‘as long as we still talk

derisively about the HIV/AIDS virus and its victims . . . the pandemic will remain the invisible monster that stalks us in the darkness.’’ With these words,

he immediately opened up new opportunities across the nation for social diaVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
60

logue and with his continuing strong leadership Botswana’s AIDS response has

since gone from strength to strength.

• Today, when political and other leaders come together, AIDS is on the agenda— from the G–8 to the World Economic Forum to the Organization of American

States.

The second major element is that we can now point to increasing success in countries. In the developing world there are a number of familiar examples. In Uganda,

surveys in urban areas in the early 1990s found 30 per cent of pregnant women

were infected with HIV, but there have been sustained drops since then to less than

10 per cent. In Thailand comprehensive prevention efforts mean that the number

of new HIV infections today is less than a quarter of the number a decade ago. And

Senegal is a prime example of a country where the HIV epidemic has been kept

small.

But today I would also like to draw attention to less familiar examples of success.

For example:

• In Cambodia, despite the pressures on a society emerging from genocide and

conflict, the threat of HIV in the mid-1990s was responded to, and as a result

there are measurable declines in both risk behaviours and in the levels of

HIV—the infection rate among pregnant women in Cambodia declined by almost a third between 1997 and 2000.

• Elsewhere in South-East Asia, the Philippines has kept HIV rates low with

strong prevention efforts and mobilisation across society involving community

and business organisations.

• Tamil Nadu state in India has recorded reductions in risk behaviour, reflecting

the success of the state’s comprehensive HIV prevention programme. Here, as

everywhere, these efforts need continual renewal, with evidence that reductions

in risky behaviour may have plateaued.

• In Africa, Zambia’s focus on HIV prevention among youth and its efforts to involve business, farmers, schools and religion in the fight against AIDS have also

shown success. In response to AIDS, young women in cities in Zambia have reported less sexual activity as well as increases in condom use, and the age at

which they first become sexually active is increasing. As a result, the proportion

of pregnant women under 20 who were HIV-positive had fallen from 27% in

1993 to 17% by 1998. In the Mbeya region in Tanzania, falls in HIV incidence

have come through a decade of sustained action. Building local skills and infrastructure has been a core part this effort, along with generating political support and working through schools, health centres, churches, village committees

and local businesses to deliver AIDS information and education, treat sexually

transmitted diseases, deliver condoms, and provide community care for people

with HIV.

• Brazil provides a leading example of integrating renewed commitment to prevention with comprehensive care. In 1994, the World Bank estimated that

Brazil was heading towards 1.2 million HIV infections by 2000, but success in

prevention in the second half of the 1990s kept the total down to 540,000. In

1996, Brazil established a legal right to free medication. The numbers of patients using antiretrovirals grew from 25,000 in 1997 to 100,000 today, and the

number of AIDS deaths has fallen by 60 per cent.

• Similarly, in Barbados, planning for universal treatment access has been a core

element of a major renewal in the national effort against HIV. With an expanding epidemic in a small population, Barbados is becoming a leading regional example with the strength of its government-wide AIDS response, led by the

Prime Minister and supported by the World Bank.

The third major element is that there are now widely accepted strategic approaches which are derived from these successful country experiences. The Global

Strategy Framework for AIDS which has been endorsed by all the members of the

UNAIDS Programme Coordinating Board—including, of course, the U.S.—sets out

a common understanding of the dynamics of the epidemic and the leadership commitments that are required to reverse it. As a consequence within the UN system,

29 different UN system bodies share a common strategic plan.

The global response to AIDS has moved beyond the stage of trying small scale

experiments to see what might or might not have an effect. We are now at the stage

of translating proven approaches to full scale national responses. These approaches

include:

• Building broad coalitions between governments and other partners from outside

government, including community organisations and business, that expand the

response to AIDS to include all fields of economic and social life.

61

• Addressing changes in the behaviour of individuals and equally of institutions.

The levers of change are to be found in pulpits and press rooms as much as

they are in health centers. Changing the norms surrounding sex—which is at

the heart of HIV prevention—has never been a task best left to men in white

coats. We need doctors and nurses to provide treatments, but when it comes to

HIV prevention, more lives will be saved by journalists, clergy, teachers and

politicians.

• Addressing the stigma surrounding HIV. A major barrier to comprehensive

AIDS prevention and care efforts remains stigma against people infected with

HIV or against those groups where HIV is thought to be most common. We

know we have a long way to go in fighting AIDS stigma when children from

AIDS affected households are excluded from school, or AIDS patients are routinely turned away from medical services for even the most straight-forward of

complaints. Responding to stigma requires involving people living with HIV centrally in the AIDS effort.

• Ensuring that responses to HIV are on a scale commensurate with the scale of

the epidemic itself. We make a real difference to the epidemic when we ensure

that local actors have the information they need to respond, and when the systems are in place that make sure they have the necessary resources available.

By delivering responses that are rooted in communities, we build to the scale

of response required.

• Responding to the epidemic with a combination of efforts. Just as combination

therapy has proved the key to cracking the nut of HIV treatment, so too combination prevention is the key to stopping the spread of HIV. There will never

be a single, one-size-fits-all solution to HIV.

The fourth major element, is that there is now a clear set of global priorities in

the fight against AIDS.

• The series of benchmark targets adopted by all the world’s countries in the UN

General Assembly Special Session on AIDS last June in New York provide a

common platform for accountability. Countries unanimously pledged themselves

to a series of targets and goals, including a 25% reduction in the level of HIV

among youth people in the hardest-hit countries by 2005, and a 50% reduction

in the proportion of infants infected with HIV by 2010. Countries also pledged

to promote access to vital drugs and ensure a supportive environment for children orphaned by HIV/AIDS. The most important legacy of that meeting has

been the upsurge in country activity dedicated to meeting these targets.

• The clear international consensus that has formed around young people as a

priority for action has been particularly important. Young women and young

men need to take joint responsibility for reducing the impact of AIDS on their

lives. They have proved themselves capable of changing the course of the epidemic if they have the right knowledge and support. In every country where

HIV transmission has been reduced, it has been among young people that the

most spectacular reductions have occurred. The UN General Assembly Special

Session on children coming up in May will again be an opportunity for all the

world’s nations to set themselves on course to reducing the toll of AIDS on infants and young people. UNAIDS, and in particular our Cosponsor UNICEF, is

ensuring that responding to AIDS is a core element of the global response to

children’s needs.

The fifth major advance is in the new realism about the resources required to

tackle AIDS.

ADDITIONAL RESOURCES REQUIRED TO ADDRESS THE AIDS EPIDEMIC

Before I come to the total requirements, I will first try to put into perspective how

additional resources could make a real difference to the epidemic. Let me take the

example of a modest annual investment of $10,000.

If we spent that money on voluntary counseling and testing in India, there are

non-government organisations that would provide good quality HIV counseling and

testing services to 10,000 people. Or in Gujarat, a hundred buses that could carry

AIDS messages for a year, reaching many thousand town and village dwellers.

$10,000 would allow the Brazilian Girl Guide and Scout movement to reach another ten thousand young Brazilians with an AIDS education kit. It would support

80 peer educators to reach hundreds of street children in every part of Brazil. It

would allow the Living Positively project in the central Goia ́s state to reach more

women with HIV, helping them to avoid transmission to their babies and training

them as peer educators.

62

In Zambia, with $10,000 there are 1000 orphans who could receive bursaries so

they can stay in school. $10,000 would let the Catholic church in Zambia train another 100 rural caregivers a year in providing community home-based care. There

are six more health workers who could be trained and supported to provide

antenatal care and antiretroviral drugs to help prevent mother to child transmission.

What does this add up to?

There is wide global recognition, including from the UN General Assembly, that

AIDS spending in low and middle income countries needs to rise to $7 to $10 billion

annually for a comprehensive AIDS response. The task we face today is to strategically multiply the number of these $10,000 investments until they reach the scale

of the epidemic itself. It is no small undertaking—a million such investments make

up the ten billion dollar target. But there are tens of thousands of communities that

stand ready to take action and are desperate to do so, and there are hundreds of

thousands more to which success could be spread.

A more detailed breakdown of the estimated total spending need has been made

by an international group convened by UNAIDS and published last year in Science

magazine. It shows there are major differences between regions in the balance of

spending needed to respond to the HIV epidemic. In Africa, where 28 million people

are already living with HIV, roughly two out of every three dollars would be needed

for care and support. In Asia and other regions where the greatest opportunity still

exists to prevent massive spread of HIV, the majority of funding would be directed

toward prevention programs.

Almost one-quarter of the estimated need in prevention expenditure is for education, counseling and mass media communications aimed at youth to help them

avoid becoming infected. We need to provide good information and support to youth

before they become sexually active and provide better services and a safer environment once they do become sexually active.

Also included in the estimates are the costs to achieve the global goal to reduce

mother to child transmission of HIV and thereby reduce the proportion of children

infected with HIV by 20% by 2005 and by 50% by 2010. We can achieve this with

known technologies that are appropriate in developing country settings. Our challenge is to build up the infrastructure and enhance human capacity to implement

these programs for the largest possible number of women. Achieving this goal will

save over 100,000 infant lives in 2005 and by 2010 the cumulative number of babies

saved would be more than 1.3 million.

Assistance to communities and for school fees could require $700 million in 2005.

By 2005 there may be as many as 19 million children orphaned by AIDS. This number is so large that even extended families will find it hard to cope. We must assist

the communities where these children live to provide care and support and provide

special assistance to ensure that these children have educational opportunities and

do not end up in the street.

The business sector has an important role to play in funding the expanded response. Approximately 7% of the total resource need is for workplace prevention programs that can be funded by private enterprises. Many employers are also funding

advanced treatment for their employees. Business involvement is crucial, not only

because bottom lines are being hurt by AIDS, but also because business is often in

the best position to reach its staff and the communities they live in. This is especially the case where there are mobile workforces, and men especially are removed

from their families to find work—in this context, our definition of risk group need

to expand beyond the obvious examples, like miners, to include others, for example

trainee bank managers.

Roughly a quarter of the total resource need is for anti-retroviral drugs. Negotiations with the pharmaceutical industry have resulted in significant price reductions

that are beginning to make it feasible to deliver these life saving drugs to those who

need them. But progress in delivering treatment needs advances on three fronts simultaneously:

—finance;

—stronger health systems, so these drugs can be delivered and their health benefits maximized; and

—the expansion of voluntary counseling and testing services since the great majority of people around the world who are living with HIV do not know whether

they are HIV infected, an obvious prior condition of treatment access.

63

CAN EXTRA RESOURCES BE SPENT WISELY AND EFFECTIVELY?

Countries do have the capacity to programme substantially increased levels of

new AIDS funds. UNAIDS has just finished an assessment of the current state of

programme readiness which has shown that the majority of countries assessed have

already completed much of the planning and programme development work required

to be confident of success in expanding their responses to AIDS. There are still some

gaps in programme preparedness, especially in the monitoring and costing of plans.

However, it is clear that developing countries are seriously engaged in detailed strategic planning on AIDS.

AIDS planning was well developed in 93 out of the 114 countries assessed— though there remain major challenges in roughly a third of the countries assessed— particularly in Africa. There are five core components to AIDS readiness: national

AIDS plans, the capacity to operationalize the plan, costings, a monitoring and evaluation strategy and mechanisms that can achieve coordination among governments,

non-government actors, the UN system and bilateral donors. Across the globe, there

are 24 countries assessed where all the elements of comprehensive AIDS programming are already in place. At the other extreme, there are 8 countries which are

yet to develop any of the elements of readiness.

One of the ironic benefits of a well-advanced epidemic in much of Africa is that

there are good estimates both of the scale of the epidemic and of the resources needed to mount a response. The sea change among African leaders and communities

to deal frankly and firmly with the challenge of AIDS is now apparent. Most governments have shown themselves willing to channel public resources to community and

civil society organisations. But the systems to support the renewed commitment in

most areas of prevention, treatment, care and impact mitigation remains weak. An

important positive development has been the more effective and transparent use of

resources. There are twelve African countries that have established a management

capacity to deal with big increases in funding through the World Bank’s Multi-country AIDS Programme for Africa and another 15 are establishing the fiduciary infrastructure required.

Our assessments of AIDS programming around the world also indicate that there

is a compelling need for more intensive planning and programme development for

effective responses in the education, social welfare, agriculture, and other sectors.

Programme development in these sectors has lagged considerably behind the health

sector.

The resources gap

Mr. Chairman, committee members, we are currently far from having secured the

$10 billion required for a comprehensive AIDS response in the world’s low and middle income countries.

In these countries in 2002, somewhat over $2 billion will be spent on AIDS, including the $1.7 billion made available by the international community. International spending is joined by significant national government expenditures on

AIDS, which in middle income countries like South Africa, Brazil or India run to

the hundreds of millions, but elsewhere are much smaller.

The gap between current expenditure and total needs is so large, that moving to

$10 billion of expenditure immediately is impracticable. Instead, we need to envisage a route to a comprehensive response where the available funds progressively increase over the next four years.

If today’s expenditure on AIDS were to be maintained only, next year’s funding

gap will be greater than $2 billion growing to at least $7 billion by 2005. The implications are quite clear and represent a major challenge for the development of vigorous resource mobilisation strategies.

To achieve our objective of scaling resource availability to keep pace with programming capacities, we need to see a roughly 50 per cent increase in funding each

year, in each of the next four years.

The funding required neither could nor should come from a single source. Only

when funds are maximized from all sources can we claim a comprehensive AIDS response.

There are five distinct groups of actors involved in responding to AIDS. Each of

them has their own advantages in supporting a comprehensive AIDS response, both

in relations to the resources the can mobilize but also in the tasks and responsibilities they perform best.

• First are developing countries themselves. National ownership and responsibility is a sine qua non of effective AIDS responses and it needs to be accompanied by budgetary allocations. A clear expression of commitment has come

from the African continent with the Abuja Declaration adopted at the OrganizaVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00067 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
64

tion of African Unity’s special summit on AIDS last year which included a

pledge that 15 per cent of national budgets would be allocated to health to help

fight AIDS and related diseases.

• Second are bilateral donors whose comparative advantage lies in being able to

draw on domestic technical resources, for example within their universities and

national programmes, and their capacity to build solidarity directly between

their own communities at home and those in the recipient countries—for example through networks of non-profit organisations. Currently, the U.S. accounts

for approximately one-third of the bilateral resources focussed on HIV/AIDS.

• Third are multilateral organisations which are particularly well placed to ensure that internationally accepted scientific and technical standards are applied,

to help promote consensus on the effective approaches to complex and difficult

social issues, and in the case of the World Bank credits, to facilitate the

internalisation of new resources within the budget and finance mechanisms of

countries, contributing to longer term financial sustainability of programmes.

• The fourth group, international NGOs and business, is becoming increasingly

important. The size, range and sophistication of business involvement in the

fight against AIDS has grown enormously over the past few years, although it

is still only a faction of its potential. Business knows it needs to protect its investments in workforces and in markets against the impact of AIDS. Some of

the most productive business initiatives in AIDS have capitalized on key business strengths. For example, UNAIDS has worked with MTV, which knows a

lot more about holding the attention of a teenager than we do. UNAIDS is also

working with Coca Cola in Africa—where in Kenya Coke’s vast distribution network has been used to get out educational material on AIDS. There are also

now a number of primarily U.S.-based foundations that have made significant

commitment to global AIDS efforts, notably the Bill and Melinda Gates Foundation. But as well, there are many other U.S.-based foundations whose AIDS

work joins their long history of concern about health and progress—the coalition

of Foundations supporting the HIV prevention among women and prevention of

mother-to-child transmission is just one of the many examples, and it includes

the Rockefeller, Bill & Melinda Gates, William and Flora Hewlett, Robert Wood

Johnson, Henry J. Kaiser Family, John D. and Catherine T. MacArthur, David

and Lucile Packard, and UN foundations.

• The fifth and the newest actor is the Global Fund. Its comparative advantage

must be in its ability to focus new resources, rapidly and directly, on the programmes with the best chance of success, in the countries with the greatest

need.

THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA

The establishment of the Global Fund to fight AIDS, Tuberculosis and Malaria

has signaled the new decisiveness in global AIDS efforts. It was only April of last

year that UN Secretary-General Kofi Annan declared at the Organization of African

Unity’s Special Summit in Abuja that the world needed a new ‘‘war chest’’ in the

fight against AIDS. The Fund will approve its first proposals this April—less than

a year after the Secretary-General’s call to action.

In 2002 the Global Fund has around $800 million available to it to disburse, and

the sources of these funds are largely G–7 pledges. Of course, the Fund will be considering TB and malaria as well as AIDS, although AIDS clearly has the greatest

proportion of the needs. The presentation I and Dr. Brundtland, Director-General

of the World Health Organization, made to the first meeting of the Board of the

Global Fund estimated that AIDS accounts for 76 per cent of total global needs, tuberculosis 19 per cent and malaria per cent.

The Fund has been constituted as a financing instrument to complement the work

and responsibilities of existing organisations. Its efforts will therefore be concentrated where they are most needed: on generating and making available additional resources. The Fund is there to support what is happening at community and

country level—proposals have to be owned in the places where the money is going

to.

The Fund is a public-private partnership—its Board includes business representation, as well as non-government organisations and representatives of the communities directly affected. The UNAIDS Secretariat, together with our Cosponsors the

World Health Organization and the World Bank, sit on the Board. Part of our role

will be to help countries in the development and preparation of proposals and to

make available our expertise and networks available to the Fund to ensure it has

the best possible advice about where its money will make a key difference.

65

Already, regional planning has taken place— earlier this month a meeting for the

Asia-Pacific region demonstrated the enormous interest in the Fund from countries,

and their preparedness to put forward the best possible proposals.

In calling for proposals, the Fund has declared its intention to promote partnerships among all relevant players within countries and across all sectors of society.

It will build on existing coordination mechanisms, and promote new and innovative

partnerships where none exist. Proposals will be considered through country coordination mechanisms, but eligibility for funding is not restricted to governments: public, private and nongovernmental programmes can be funded.

The Fund will support programmes both within and outside the health sector if

they are technically sound, cost-effective and focus on performance by linking resources to the achievement of clear, measurable and sustainable results.

The support for the Fund in the U.S. Congress was a crucial factor in meeting

the rapid timetable for its establishment. The two tranches of $200 million so far

allocated to the Fund by the U.S. government have also set the pace for pledges

from the rest of the world: total pledges to the Fund now stand at just under $2

billion.

A very wide international coalition has come together in the Fund, and in spite

of the range of interests represented, it is notable that key considerations set by the

U.S. Congress have been met including that:

—it will coordinate its activities with governments, civil society nongovernmental

organisations, UNAIDS the private sector and donor agencies; and

—nongovernmental organisations, including faith-based organisations, will be eligible for assistance, and eligible areas include treatment and the provision of

interventions to reduce mother-to-child transmission.

Mr. Chairman, committee members, pledges to the Global Fund already represent

a 50 per cent increase on the international funds available to fight AIDS. This is

progress!

The challenge now is to build on this progress: to make the Fund work well by

demonstrating that it can spend wisely, spend rapidly, and show results. If it does

this, it is our hope that it will be an increasingly attractive proposition for donors,

and the Fund will grow.

MOVING FORWARD

Mr. Chairman, committee members, AIDS is a massive global problem, but it is

a problem with a solution.

The tools for effective responses exist. In the vast majority of countries around

the world, there are detailed plans for dealing with AIDS. There are countless communities ready to take action. And in order to build success, increased financial investment needs to be equally matched with investment in human resource and institutional capacities.

If we are to achieve success, we need to know how our progress is going. Critical

U.S. support in monitoring the epidemic and in evaluating the success of AIDS programs has put us in a better position than a few years ago. The cooperative framework for monitoring and evaluation that the UNAIDS Secretariat has been able to

deliver has resulted in a level of consensus and influence at country level which has

far surpassed what any one agency alone could have achieved.

Of course, for AIDS spending to be worthwhile, it needs to be able to flow efficiently to the levels it is needed. Improving both governance and the efficiency of

resource transfer mechanisms remains a core priority for UNAIDS, including our

Cosponsors, particularly UNDP.

Mr. Chairman, committee members, the fight against AIDS is a race, and so far,

it is the virus that has been winning. But we are now in a position to make a leap

forward—a leap that will for the first time put us ahead of HIV. I would be kidding

myself as well as all of you if I said the task was an easy one. There are huge challenges:

First, the challenge of scale. There are perhaps a few thousand really effective

AIDS programmes and activities around the world today. Unless we can rapidly escalate this number to a few hundred thousand, we will fall behind in the race.

Second, the challenge of coordination. Funding for AIDS has increased. The number of players has increased. Different parts of government are now substantively

involved. International and national non-governmental players are increasingly important. But while we must celebrate this renewed level of activity, unless there is

a corresponding increase in coordination, we will still fall behind in the race.

Third, the challenge of resources flow. There are still far too many blockages between resource availability at global level and resource needs at the local, village

66

and neighborhood level. Unless we can unblock the resources pipeline, we will fall

behind in the race.

Fourth, the challenge to be led by science. A pragmatic response to evidence must

be our guide in the AIDS response, already too much effort has been diverted by

those wishing to turn AIDS into their own private bandwagon. Responding to AIDS

will always touch raw nerves around sexuality, drug use, relations between men and

women, and the limits of personal confidentiality. But unless we can find the ways

to agree to be guided by evidence and reason, then we will fall behind in the race.

Meeting these challenges requires us to marshal all we know about moving forward against the HIV epidemic. We know what to do. We know how to do it. We

know it needs to be done at the right scale. We know what it costs. We are clearer

than ever before about the ways in which increased spending would make a real

difference to the course of the epidemic.

All these elements must now be put together. Success against the epidemic will

be achieved when all the players involved play to their strengths.

Mr. Chairman, committee members, U.S. support for the global AIDS effort is directed in three areas:

• One, to the multilateral system, in particular the international organisations including UNAIDS and our Cosponsors;

• Two, to the new Global fund to Fight AIDS, Tuberculosis and Malaria; and

• Three, in bilateral efforts, including those of USAID, Health and Human Services, the CDC and research efforts through the NIH, as well as other programmes including that of the Department of Labor.

The United States government has long supported global AIDS programs and underwritten a research effort that remains a beacon of hope for people affected by

the disease. It remains to the enormous credit of the U.S. Department of Health and

Human Services through its Centers for Disease Control and Prevention that its expertise in identifying disease outbreaks was applied rapidly and effectively in the

case of AIDS, and its continuing role both internationally and domestically has contributed enormously to the effectiveness of AIDS responses. More recently, initiatives have expanded—the U.S. Department of Defense, through the LIFE project,

has been a key player in responding to AIDS awareness among the uniformed services, working with UNAIDS together with the contribution of one of our Cosponsors,

UNFPA.

The U.S. is the first developed country to publish its 2003 budget. Most others

will be following suit in the next few months—and I hope they will be able to take

note that U.S. proposals for international HIV/AIDS assistance for 2003 are on an

upward trend. The U.S., like every other donor, will need to do more if the world

is to respond effectively to AIDS. American bilateral efforts on HIV/AIDS—at

USAID, Health and Human Services including CDC, and the Departments of Labor,

Agriculture and Defense—and critically now the Department of State—will also require further strengthening to keep up with country needs. Unparalleled American

know-how in such vital fields as medical training, core public health functions, and

service delivery are needed more than ever to assist developing countries.

The U.S. has already proved itself willing to take its leadership role in making

the required leaps forward. We would strongly encourage you to continue in that

leadership role, and look forward to our continued partnership with you in meeting

this great challenge.

Thank you for your attention.

The CHAIRMAN. Thank you very much, Doctor.

Why don’t begin with Senator Feingold?

Senator FEINGOLD. I thank you, Mr. Chairman. I thank you for

your testimony.

Some in the advocacy community have called for the establishment of a global procurement fund that would try to secure economies of scale when it comes to pharmaceuticals to treat HIV/AIDS

and opportunistic infections that are associated with the disease.

What is your opinion of that idea and what role, if any, is to be

played by the UN and UN agencies in terms of drug procurement

today?

Dr. PIOT. Thank you, Senator.

67

There are certainly advantages of large procurement schemes.

But as was said this morning also, the Global Fund is meant to

benefit from existing mechanisms, and when it comes to global procurement, for example, UNICEF has a major supply division which

is taking on procurement for medical supplies and others. I think

it is probably the most cost effective way to make use of these existing procurement systems. That is one of the conclusions also of

the board of the Fund a few weeks ago where a small working

group is now looking into the most efficient and effective procurement mechanisms. But there is no doubt that that will drive the

price down just because of economies of scale.

Senator FEINGOLD. So, that is not a role that is envisioned for

the Global Fund.

Dr. PIOT. For the fund itself, no, but it should tap into existing

procurement schemes.

Senator FEINGOLD. In your experience, do different members of

the donor community have different priorities when it comes to addressing the AIDS crisis? What about the priorities of states that

receive assistance from UNAIDS? Do you find that their priorities

are different from those of the donors?

Dr. PIOT. Well, I could safely say that today the situation has

changed dramatically from where we were, as I mentioned, 5 years

ago, and that in my mind in all African countries, for example, and

in all Caribbean nations, AIDS is one of the top priorities for the

leadership. That is less so, I would say, in Eastern Europe with the

exception of Ukraine where the President himself is chairing the

National AIDS Council and has declared 2002 the Year of AIDS.

And it is also highly variable in Central Asia. Let us not forget that

in Eastern Europe and Central Asia, we have got the fastest growing AIDS epidemic in the world. So, it is a very variable picture

but there is good progress.

The key challenge now is not to convince any of these leaders,

certainly not in Africa, that AIDS is a threat to their security, to

the survival of the nation, but is to assist with the how. How are

we going to put in place effective mechanisms that are going to

make a difference at the community level?

Senator FEINGOLD. Let me try another angle on this. How does

UNAIDS work to avoid sort of a one-size-fits-all formula in the approach to prevention, care, and treatment around the world? If you

could actually give an example of two very different approaches

that UNAIDS is taking in different places just to illustrate it, I

would appreciate it.

Dr. PIOT. Yes. When I got into this job, this was one of the questions I was struggling with because before UNAIDS existed in the

UN system, there was indeed the blueprint approach to AIDS.

Whether you were in China or in Uganda, it was all the same.

First of all, culturally that will never work, and second, the needs

are different.

When I look at the resource needs, for example, the estimates

that we made to come to the $7 billion to $10 billion figure, are

based on the fact that in Africa the needs, in terms of treatment

and care, are far greater than, for example, in Asia where a much,

much lower percentage of the population is infected.

68

The principle should be really that each country has to define its

own road map, but the principles and the goals are the same everywhere.

So, concretely in China, our approach has been one of working

with the government more at the political level to lead to a recognition that AIDS is a problem and working with the various provinces, because it is a highly decentralized country.

When it comes to a country like Uganda, there we have been

working trying to set in place two things. One is, mainly through

UNICEF, youth programs, prevention of HIV among young people,

saving the current generation, which should be a top priority, and

then second, expanding access to treatment and care by decreasing

the price of antiretroviral drugs, by putting in place care centers

and training of health care workers.

So, these are two examples, but there are so many.

Senator FEINGOLD. Thank you very much, Doctor. Thank you,

Mr. Chairman.

The CHAIRMAN. Senator Frist.

Senator FRIST. Thank you, Mr. Chairman.

Dr. Piot, thank you for your leadership. I was just talking to the

chairman impolitely as you were talking, basically saying that of

all the witnesses that we will see today, the person who has seen

the most on the ground, has had the most sort of global exposure

but really on-the-ground exposure as to what works and what does

not work in a range of countries, like in your first slide presented,

is you. Therefore, I would like to have you comment further or

elaborate a little bit more on what you just closed with.

You heard me ask the first panel, and I will get their answers

in writing. But to link care and treatment to prevention, which as

a physician and as a real believer in public health and the impact

you can make, but the demand must be that you link all three.

In this country today, if you look at the President’s budget, there

is an emphasis on really all three, with a heavy emphasis on research, but also the treatment end as well as the prevention end.

Here in this country when people look globally, they think of treatment being antiretrovirals. Period. The concentration has been on

intellectual property rights, which I think is a very appropriate discussion. It has been on diminishing or lessening the cost.

In Africa, it was amazing, Mr. Chairman. Now antiretrovirals

are down probably a tenth of what they were 18 months ago. Still

not low enough. We still have got to go a long way, and we have

got to keep pushing in appropriate ways there.

But what has been remarkable to me that I think we need to understand better is this linkage of care and treatment, opening up

hope, the power of nutrition, the power of even herbal treatments

that in this country many times are diminished, that care and

treatment is not just antiretrovirals. If you focus just on

antiretrovirals, they will not be delivered because of really what

you said initially in terms of capacity and capacity building as we

go forward.

Could you just paint that picture based on your experience? Not

in my words but your experience.

Dr. PIOT. Thank you, Dr. Frist.

69

I think it is really at the heart of, let us say, the substantive

strategic debate at the moment.

When I look at Uganda, for example, the success has been mostly

in declining infection rates.

Now, I mentioned the elements of success, but one very important element for me was that people with HIV who were affected

or whose partners have it or died from AIDS organized themselves

and started to organize also some care, some treatment. This was

even before antiretrovirals existed and were introduced here.

There is one element that never figures into economists’ cost effectiveness calculations and so on, and you mentioned it, Dr. Frist,

and that is hope. It is hope that drives communities that drives social reform. So, this is where I believe now, as recognized by the

declaration of commitment that came out of the UN General Assembly, that care and treatment are an integral part of the response, just as prevention. But sometimes I feel that the debate is

only on treatment or sometimes it is only on prevention, and we

have got the supporters of both. We really need both together.

What is the link between these two? That is the voluntary counseling and testing. Ninety-five percent of people with HIV in the

developing world have no clue that they are infected, that they are

HIV-positive. Just imagine what that is. Of the 40 million people

who are infected, they do not know. Not that they do not want to

know, but first, there are no testing centers or they do not have

the money to pay for a test. Or if they go for a test, all that is at

the end of the test is discrimination. They lose their job. Their husband may kick them out and there is no treatment. So, this is a

crucial issue to put in place in terms of programs.

When we talk about treatment, I think we have learned a lot.

Four years ago, we started with UNAIDS in Kampala and in

Abidjan, in Ivory Coast with some pilot projects to learn what are

the best ways to improving access to treatment and care for people

with HIV in really poor resource environments. What we have

learned is that you can do a lot. You can do a lot on the one hand,

with no antiretrovirals, treating the symptoms, keeping people

alive with treating and preventing opportunistic infections, but also

that antiretroviral therapy in Africa in capitals is possible. It is not

possible, I think, to offer it overnight for everybody, both for economic reasons and because of the infrastructure that is not there,

but it can be introduced. Patient compliance is as good as anywhere else in the world. Why would it be different?

So, what I feel is that in each country we need to define exactly

what we are meaning. There needs to be a societal debate and if

that debate is not there, if it is not planned in a way that access

to treatment will be widened, what happens is that only those who

have the means to pay privately will have access to treatment. We

need to make sure that systems are being put in place, that money

is going to come—and I think it is starting to come.

The CHAIRMAN. How do you do that, Doctor? How do you do the

first piece?

Dr. PIOT. We are not living in a desert in the capitals. When Dr.

Frist is doing surgery in Africa, it is in existing hospitals and

health care facilities. That is where we can start, and that will be

the easier part, the first part.

70

To go beyond that is going to be the more difficult one, and that

is where we will have to invest in training, in, let us say, community-to-community programs, medical assistance, and all the things

that we have said this morning. But I think for today to expand

that, that is feasible.

In terms of the financing of all that, who is going to pay for it?

That is also another part. Here we have got to see that the pots

of money that pay for prevention and that pay for treatment and

care in about every country in the world are different pots of

money. So, I think we need also to look at that in a more refined

way. Financing for health care, including in developing countries,

is not going to come only from the outside. People are already paying. The problem is that to pay for antiretroviral therapy, it is just

not going to be possible without massive external funding, at least

in Africa.

Senator FRIST. Again, even in listening to your comments, when

you are really on the ground, Dr. Piot, the antiretrovirals are there.

I do not know what the number one killer really is with HIV/AIDS,

but say it is tuberculosis.

Dr. PIOT. TB.

Senator FRIST. TB and that is what we say because so many people have TB. I do not think it really is. Anyway, it is an opportunistic infection of some sort.

Dr. PIOT. Right.

Senator FRIST. It is hard for me to explain to people, when you

have that little virus which is winning the war—and I love your

analogy. It is winning the war. Even with the number of people

that die, it is winning the war as we go forward in terms of the

new infections.

If we cannot even treat the opportunistic infections or we do not

have the capacity, it is going to be asking a lot to pull down an

antiretroviral. I agree compliance will be there if the system is

there, but globally I do not think we are adequately addressing the

treatment for other sexually transmitted diseases, the opportunistic

infections which we know with a certain input, will prolong life significantly if we can adequately treat tuberculosis or any of the

other infections. I do not see, even in your comments, why we do

not put more emphasis on treatment of those opportunistic infections and nutrition, which when you go into these communities,

you see it has such a huge, huge impact.

Dr. PIOT. No. I do not think we disagree at all because the way

I see it is prevention has to be scaled up, treatment for opportunistic infections, care for orphans and support, but then at the same

time, I think we should not wait until everything is in place to

start with the antiretroviral therapy there where it is possible. Because I also think that we can never have a real impact on this

epidemic if we go with, let us say, a 10 percent approach—we have

tried that for 20 years—and do a little bit of this and a little bit

of that. I think that is where we are now getting into at least gearing up to a full response. But I am the last one to underestimate

all the problems.

My biggest question is how to do this outside the big cities. In

the cities I think it is possible, but outside is where we have got

to build the systems. That is why I put so much emphasis on the

71

capacity building, and the illusion that we sometimes have in the

development assistance community is we give a bit of money to do

certain things, but then we tell that NGO or that church or government you are not allowed to use that money to train your people.

We are pushing education but we do not invest in the teachers who

need to be trained because there are so many who die from AIDS.

That is a real problem.

Senator FRIST. To even take that one step further, it is easier

from our perspective, as we try to build support to increase the

funding, for people to focus on one element of like antiretroviral

therapy and just say, oh, it is too expensive, we cannot do anything, and hide behind that and not address the capacity building.

I link it very much to treatment of opportunistic infections because

you get your nurses out there and you get the communication, you

get those teachable moments there. I think that is the challenge we

have.

Mr. Chairman, I know we have got another whole panel, but can

I just bring up one thing?

The CHAIRMAN. No, no, keep going.

Senator FRIST. It is totally different. And that is the orphans.

Again, the last panel will bring it up. But having the opportunity

to have somebody such as yourself here. Ten million, thirteen million. And orphans—the definition just so people understand—does

not necessarily mean both parents are dead. You might give me the

real definition, but what it means is one of the two parents have

died of HIV/AIDS.

But, in essence, we have got 10 million to 13 million out there.

We will go to 40 million within 10 years. We have got to address

it. As I said, when you are going through the areas and you do not

see any people middle aged because the parents are dead and you

have a grandmother taking care of one generation and the next

generation, and then the generation of all the children of 28 children, you know we have got to address that issue.

Now I am at a loss of what we do. You can talk about it and you

can link the care and you can link the hope. But what can we, sitting up here, really be doing to address that issue?

Dr. PIOT. Well, that is probably one of the most complicated

issues, in addition to being the most tragic one.

First of all, on the definition, what we use is that children who

lost their mother because that is the key in terms of survival. By

June we will have also statistics on orphans who lost both of their

parents and so on. So, we are refining the definition.

I think that one of the main consequences will be more street

kids, more teenagers on the street. Some of these orphans are infected with HIV as well. Others will grow up and will become teenagers. We have a whole generation of what is called desocialized

youth that is growing up.

Senator FRIST. Can I just add to that? When we think of terrorism, when we think of lack of civil society, when you see kids—

they are good kids, but they just have nobody to look to—and you

think of terrorism and you think of the lack of order and the risks

of terrorism in the past, all of a sudden, all these images start linking together because it gives them nobody to turn to.

72

Dr. PIOT. Exactly. I think these are an ideal reserve of kids, adolescents who, you know, you put a collection cup in their hands and

here we go. Anybody who is looking for cheap soldiers.

The CHAIRMAN. On this orphan question, which sounds so antiseptic the way I just said it—I do not mean it that way—based on

the definition being used for an orphan, are any of these orphans

in collective care anywhere? Most Americans think of orphans as

being in an orphanage. They think of it as being in some sort of

state-provided care. Paint a picture for us of what we are talking

about when we are talking about the millions orphans we are referring to. Are these kids like the orphans that existed in Brazil earlier on, literally wandering gangs of 12- and 13-year-olds led by 14-

year-olds? I do not mean gangs in the sense they are murderers.

I mean just in terms of their family. What are we talking about

when we talk about these orphans in terms of where they are located?

Dr. PIOT. Sorry. Wherever——

The CHAIRMAN. No. I do not mean what country. Let me just give

you my conclusion and maybe you can respond. My impression is

that when we talk about orphans in Africa, orphans as a consequence of the loss of a mother to AIDS, we are talking about that

child being in the extended care of a grandmother or of the family

next door or just literally subsisting on his or her own on the street

as opposed to orphans being collected into a social agency where

they are given three square meals a day, able to be tested as to

whether or not they are HIV-positive, et cetera. That is what I am

trying to get at.

Dr. PIOT. Right. First, a kid who lost her mother, in general, also

will have no father or have lost the father to AIDS because of the

sexual transmission issue.

But second, indeed, very few of these children will be in institutions. We also do not think it is the first option, the first solution.

Fortunately, particularly in Africa, there are extended families

where there is a tradition that not only orphans but children in difficulty will be taken up. But these families are stretched to the

limit, and that is not working.

There are three priorities for dealing with orphans. We have

done some work—this was in Zambia with UNICEF and with

USAID—mapping out the orphans, where are they, what are their

needs. It is quite predictable. It is food, it is a roof, and it is school.

The most important investment I believe is in keeping these kids

in school. For example, I know in Zambia, because I just talked

about it at the World Economic Forum, for $10,000 you can keep

1,000 orphans in school for 1 year. We are not talking about billions here. That is very concrete. And emphasizing vocational training so that they learn a job and that they do not end up in the

street in gangs and so on.

The CHAIRMAN. The reason I ask such basic questions here is

that to a lesser extent than Dr. Frist, but nonetheless to a significant degree, most of us who serve on this committee and serve in

the Congress or the Senate or in various positions of authority are

aware of the nature, scope, and the demographics of the problem

we are talking about. Most Americans and I suspect most EuroVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00076 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
73

peans do not have it down to intellectual bite-sized chunks that

they can understand.

For example, when I go home, Doctor, my constituency is a fairly

well educated constituency. Where I come from, in relative terms,

is one of the most affluent States in the Nation. I will get off the

train tonight and someone will have watched this on C-SPAN or

watched some news coverage of it, and they will ask questions that

in a sense, to use the vernacular, bring me up straight, make me

realize that I speak too much like a foreign relations expert or I

speak too much of the international lingo about what the problem

is.

When I go home someone will ask me about orphans. The conductor will ask me on the train, he will say, if you have all these

orphans, why do we not just test them all in the orphanage and

find out who has AIDS and cannot we help deal with the problem

that way? And I say, no, no, no, that is not how it works.

When you talk about education—how can I say this politely? One

of the problems the Senator and I have had—and it is presumptuous of me to speak for him. Our interest in this subject is something that 10 years ago, for example, was not immediately embraced by our constituencies. Among some Members of this Congress, the notion that we would spend time, energy, resources on

this issue were almost viewed in moral terms.

But once you begin to break this problem out and the reason why

I think Senator Frist is so effective, if you notice, he is always talking about on the ground. He has changed the mind of some of our

colleagues to vote for more money or vote for the money requested

by the administration by saying ‘‘are you aware.’’ I notice he has

a picture in his lap right here. Are you aware that this is what we

are talking about? And he shows a picture of a village or shows a

picture of 10 or 12 children surrounding him in an area, or he tells

a story about how in an extended community where, to use the

phrase which got battered around for political reasons up here, it

takes a village to raise a child, that African proverb is one that actually functions, that people actually reach out. When you put it

in those terms, we find that people come along and say, oh, I got

that. I will vote for that.

I am going to get in trouble here, but for example, we have a

great fight here in the United States about the availability of

condoms for youth. Yet, we fund a significant amount of money for

condoms for the rest of the world. People do not make that connection here. They do not think about it.

So, the reason why I am trying to get you to even paint a more

vivid picture about orphans or prevention, it is because the more

it can be broken down into terms that our collective constituencies,

whether it is in France or in the United States, whether it is in

Germany or it is in Brazil, the more I believe generic and broad

support we get across the board for doing more and more.

I am going to ask you this one question and perhaps you could

give me some concrete notions about prevention. When you say prevention here in the United States, a whole bunch of different images pop up in people’s minds. Not negative, but what do you mean

by prevention? What are the prevention programs or initiatives

that are the most successful in your experience? And it may vary

74

from country to country to country. But give us some examples of

prevention programs, if we were able to fund more of them, encourage more of them, that would have a greater impact on the spread

of this disease.

Dr. PIOT. Well, thank you, Senator. That is a long story, but I

will try to be as concrete as possible.

I think that all evidence today shows that it is in young people,

youngsters, that we have the greatest chance to succeed with prevention programs, with education, contrary to what many older

people think. When you look at the curves of declining infections

in the countries that I mentioned, it is always in young people 15-

to 24-year-olds that you see the first decline, the most rapid one,

and we heard some examples also of postponement of first sexual

intercourse, higher condom use, less partners, and all that.

And what works there? It is not someone like me telling them

this is good for you or this is not good for you. That does not work.

Certainly when I was 15, I would not have listened. It is using the

youth culture. What we have been most successful with is working

with singers like Youssom N’Douf in Senegal who gives concerts,

working with MTV. I think our most successful partnership with

a private company in UNAIDS is that with MTV, a very unlikely

partnership between a UN organization and MTV for the last 4

years.

The CHAIRMAN. I do not think it is unlikely at all.

Dr. PIOT. Last year on World AIDS Day, we reached 1 billion

young people—1 billion—at a cost to us of half a staff member,

helping to formulate the message and then MTV does the packaging in India, in the Caribbean, in Brazil and so on.

So, that is one principle, trying to work with sports heroes and

singers. Sports and music. That is the youth culture. There were

the soccer games in Africa 2 weeks ago in Mali. For those of you

who have seen it and watched it on TV, it is mostly young boys

watching it in Africa. Every match, there were eight messages, and

we know that that has more impact again than 1,000 billboards.

The second way is so-called peer education, young people talking

to young people in the language that they understand. So investing

into that, but making sure that there is quality control in the sense

that it is not just anything that they say, but things that make

sense.

We have also been working with church groups because there are

different types of young people. So, you are reaching another one.

And in Kampala, for example, there is facilitation, as we say in the

UN, to an open environment. Create a space for young kids that

they can talk about that. Radio programs. In Zambia, there is a

whole club which is called Post-test Clubs and clubs of students

against AIDS. It is relatively different from one place to another,

but the principles are exactly the same.

The CHAIRMAN. Now, one last question on that point because at

least I think this is helpful in being able to carry the case beyond

where we have already carried it here and what we need to do in

terms of resources because you talk about the gap between projected resource availability and program capacity, that you are

building program capacity, but in resource availability there may

be a very wide gap.

75

What kind of resistance institutionally from the governments do

you get, and does it vary, for these kinds of initiatives, the kinds

you have just acknowledged and you have just stated? Because we

find even in this country initially there was real reluctance to talk

about it, talk about safe sex. There are cultural impediments.

Without getting into which countries, but how much of an impediment toward this notion of prevention are due to cultural impediments that exist? Or is it not that much of a problem?

Dr. PIOT. Well, first I would say, Senator, that every society,

every country I have been in is going through the same problems

in recognizing that there is an AIDS problem and then has the

same difficulties in talking about sex, the openness about it. Everybody does it or most people, but to talk about it in a way that will

protect people and save lives is one thing.

Then the other thing that I see in common everywhere is the

stigma associated with AIDS that makes it difficult. That is why

this leadership thing is so important. I was with President

Mandela on World AIDS Day in ’99. He addressed the nation on

AIDS for the first time, and he extensively used the word

‘‘condom,’’ talked about it and was very explicit. That makes a real

difference because there is resistance in South Africa or in my own

country.

There is usually also resistance particularly when it comes to

HIV prevention among young people. My kids do not do this. Or

sex education in schools. We know from surveys that sexual activity may start at a very early date. So, it is really critical that problems are being addressed before they become sexually active. These

are problems we see in every society.

We have really taken an approach that is extremely inclusive,

working from above and from below, above with the leadership. I

am not only thinking of the president, although a president talking

about it makes a difference, or the first lady in many countries. In

Ivory Coast, for example, or in Rwanda, the first lady is really

spearheading the AIDS campaign and it is easier, when she talks

about it, for others who are teachers to talk about it because our

big chief has talked about it, our first lady.

Also, this is why it is so important to have the traditional chiefs

and the religious leaders, wherever they come from, to have them

on board. That is changing. I can see there also a sea change over

5 years ago.

Perhaps the most important factor has been that certainly in Africa there is not a single family who has not lost a relative from

HIV. So, it has come much closer to wherever we are. [start]

The CHAIRMAN. My last question is this: one of the most troubling aspects of the spread of HIV/AIDS in some countries is that

teenage girls are becoming infected at rates that are significantly

higher than their male counterparts. The number of HIV positive

women seems to be on the rise. There are a variety of reasons for

this, but one of them seems to be the fact that women do not have

as great a say in when and with whom they wish to have sex.

What programs, if any, specifically address the special needs of

women and children in terms of their vulnerability to the exposure

to AIDS? Is there any particular focus on that?

76

Dr. PIOT. Yes. Certainly it is one of the most shocking aspects

of the AIDS epidemic. We have done some work, for example, in

Kenya, in Zambia, in Cameroon, and in each place, when you look

at 15- to 18-year-old girls, their infection rate is two to five times

as high as in boys of the same age. How are these girls becoming

infected? Not from the boys of their age group, but from older men.

So, the problem is not so much with the girls, but with the sexual

behavior of the older men. That is what our programs have to address.

And it is both for behavioral reasons—the older men having sex

with younger girls, which is the case in most societies. When you

look at relationships between men and women, the males are usually a bit older than the women, but the distance can be enormous

in some societies.

And second, there is a biological reason also, and that is that

young girls, young women are biologically far more vulnerable to

infection with HIV than boys of the same age or than older women

for anatomical reasons, et cetera. We are not going to go into that

now. So, there is clearly a vulnerability, a social one and a biological one.

Ultimately there are two things that have to change. That is

male sexual behavior, particularly men over 30, the most difficult

thing to change. That is why over the last 3 years we have been

promoting that as a theme, which created a lot of resistance in

many societies, not only in developing countries but also in the

West. I can tell you.

The CHAIRMAN. I agree.

Dr. PIOT. Second is education for girls. We know also from several surveys, from Kenya to Zambia to Tanzania, that women with

a higher level of education are in a much better position to protect

themselves, to say no to unwanted sex if it is not associated with

violence. So, that would mean that if we would take away funds

from education programs to put them into AIDS programs, the net

result may be ultimately zero. That is, I think, also something we

have to bear in mind.

The CHAIRMAN. Let me ask one other question on that score. If

95 percent—I think that is the number somebody used; maybe you,

Doctor—of the people infected in—just focus on Africa, as we have,

for a moment—are unaware that they are infected, but if 95 percent of the population is aware of the extent of the disease, not

that they have it, but that it is a widespread disease, would not

that, particularly in male-dominated societies, increase further

pressure on young women because the percentage play that most

older men would conclude would diminish their prospects of being

infected would be to have sex with a younger woman? Is there any

evidence? Is that beyond just sort of a common sense assessment

or is that real?

Dr. PIOT. Well, Senator, there is anecdotal evidence for that but

not systematic evidence. It makes good sense, if you want.

But I think in all these areas, the real crime is that we have lots

of successful examples of what works and an order of magnitude

less resource than is required when we talk about all these things.

So, I hope that the U.S. will continue to lead there.

77

The CHAIRMAN. Well, I can assure you that with the leadership

of Senator Frist and others, the U.S. will try to not only maintain,

but maybe even increase the U.S. participation.

Senator FRIST. Can I make one more comment?

The CHAIRMAN. Oh, please. I am sorry.

Senator FRIST. No, I am done. I know we have got to get to the

next panel, but just following up a couple of points.

The women’s issue is huge. I will tell you, again going to Tanzania, Kenya, Uganda, and just asking the question, the same

question you asked, the answer is focusing on education for young

women. It is not just that you educate to make more prudent decisions, but during this vulnerable period where, for biological reasons, which most people do not know unless you are told—in part.

That is part of the reason. But just by having the opportunity to

go to school over that year or 2 years changes behavior for the rest

of life. It is just critically important. So, something that can be

done that will get these curves moving in the other direction as

simple as keeping young girls in school for an additional 2 years.

What happens when there is a family tragedy or times are tough,

the girls are pulled out of school first and the boys are left in

school. So, I think the question is a perfect question, and I think

we need to understand that.

Second, we have not talked about the United Nations. We talked

about leadership. Mr. Natsios implied that the leadership has come

a long way and you have done the same. I am still sorely disappointed in the leaders of the African countries, as well as people

in the United Nations, of where we are today because the leaders

have to come out and take a strong stand as we go forward. I just

would encourage you. I know you are in the middle of that. In the

United Nations, Richard Holbrooke I think did a superb job elevating this issue, a little bit uncomfortably at first, but to the leaders of the United Nations. But I think we have got a lot more to

do there. Again, I know that you are right there.

The First Lady of Uganda is going to be here next week to speak

to essentially a church-sponsored conference on HIV/AIDS. And I

agree with you. You have got to have sort of the top person, whoever it is, but having their spouses out there makes a huge difference.

Thanks for really helping us understand the issue.

The CHAIRMAN. Doctor, thank you very, very much, and thank

you for your work for so many years. I appreciate it. Thank you for

being here.

With that, we will move to our third and final panel. Princeton

Lyman, the Executive Director of the Global Interdependence Initiative at the Aspen Institute. He is also a member of the Center

for Strategic and International Studies Task Force on HIV/AIDS.

I tell you what. We will take a 5-minute break here.

[Short recess.]

The CHAIRMAN. If we can come back to order here.

As I started to say before, our panel now is Ambassador Princeton Lyman. I spoke briefly about his career in Government includes

service as Assistant Secretary of State for International Organization Affairs, Ambassador to Nigeria, Ambassador to South Africa.

He received his Ph.D. in political science from Harvard and has

78

written extensively on development, foreign policy, and conflict resolution. His book on the U.S. role in South Africa’s transition to democracy will be published this June by the U.S. Institute of Peace.

Hopefully, he will not have an extensive chapter on my shouting

match with the former Secretary of State during that period.

Dr. Ray is a public health specialist, working as Director of the

Southern Africa AIDS Information Dissemination Service, a regional information service serving the South African region. She

has worked since 1983 in Zimbabwe on both rural and urban strategies mainly in public health specializing in gender issues and communicable diseases, including HIV and tuberculosis.

And Dr. Peter Okaalet. I am pronouncing it correctly, am I not,

Doctor?

Dr. OKAALET. Yes.

The CHAIRMAN. Is that close enough for government work? If I

mispronounced it, you can call me ‘‘Bidden’’ if you like.

Dr. Okaalet is the Director for Africa Division of Medical Assistance Program International. He is a medical doctor, licensed to

practice in both Kenya and Uganda, and he holds two master’s degrees in theology, in addition to his medical training. He is not 112

years old. It is amazing you got all that in a short amount of time.

With that, let me move right to the witnesses and invite them

in the order they have been introduced to make their statements.

Again, we appreciate your patience and being here and waiting this

long. Mr. Ambassador.

STATEMENT OF HON. PRINCETON LYMAN, WORKING GROUP

CO-CHAIR, CENTER FOR STRATEGIC AND INTERNATIONAL

STUDIES TASK FORCE ON HIV/AIDS; EXECUTIVE DIRECTOR,

GLOBAL INTERDEPENDENCE INITIATIVE, ASPEN INSTITUTE,

WASHINGTON, DC

Ambassador LYMAN. Thank you, Mr. Chairman. Thank you very

much. It has not been a problem to sit here because this has been

an extraordinarily good hearing, and certainly I want to join others

in commending you and Senator Frist for this hearing, which I

think has contributed a great deal.

The CHAIRMAN. Doctor, as my friend, our friend, the Senator

from South Carolina, Senator Thurmond, would say, would you

pull that machine close to your face there? Because I do not think

they can hear you in the back.

Ambassador LYMAN. Okay. I hope they can now. Thanks.

I have submitted a statement which I would appreciate being put

in the record.

The CHAIRMAN. Your entire statement will be placed in the

record.

Ambassador LYMAN. Thank you, and I will just summarize it

here.

I have just also returned from South Africa. You can see firsthand in South Africa not only the magnitude of this problem, but

the painful and often divisive debate that this issue creates within

societies, and I will come back to that a little bit.

Here today I want to speak to the work of the CSIS Task Force,

which you have mentioned. Senator Frist and Senator Kerry have

been, kindly, co-chairs of this effort. Steve Morrison and I are

79

working on a 5-year approach to this problem, and I want to concentrate on that today because the need now, as awareness is

growing and has been created with hearings like this and a lot of

other things, is now to have for the United States and then internationally a strategic, multi-sectoral, 5-year approach that has very

specific objectives and is assured of adequate support and resources

each year along the way.

I think first we need to understand where this pandemic is moving in the next 5 years, and much of that has been discussed here.

But then we must move to such a plan.

We talked a little bit about greater awareness. Mr. Chairman,

you have talked about the American public. We have a survey that

will be just issued in the next day that was done for the CSIS Task

Force that shows a very great awareness among the American public about this problem, a receptiveness to the type of information

that has been discussed here today, a serious concern about it, and

a great interest in those programs which work, knowledge about

programs that work, and those programs will get, if this survey is

at all accurate, the strong support of the American public. And I

think that is an important element.

But there is also increased international awareness of the need

for a broad strategy. The UN General Assembly Special Session

outlined such a thing. There is a WHO commission on the relationship of macroeconomics and health, and there is, of course, the

Global Fund which deals with several different diseases.

When we look at the structure and operation of our own Government in this regard—and Senator Frist has talked about this earlier in the hearing—obviously a number of very important things

have been done, and the Bush administration has taken a number

of very important steps, the joint task force that is chaired by Secretaries Thompson and Powell, the contributions to the Global

Fund, the increase in bilateral funding. But I think, if we could

suggest, that there needs to be more understanding and perhaps

joint planning between the administration and Congress on the

roles of the various Government agencies and to assure that they

have the mandates as well as the funding to do this international

work.

If we look at the role, for example, of HHS, if it is going to assume a greater role in helping build the infrastructure, train the

people, create the capabilities abroad—and that is true of NIH and

HRSA—we have to make sure that the funding is there, that the

mandates are there, that the committees that control their funding

are seized with the importance of this. And that goes for other

agencies as well.

Now, I would like to say a word about American leadership in

this area because it is so critical. But let me put my other hat on

for a moment, work we have done at the Aspen Institute about

what the American public thinks about leadership. It is interesting

that the focus groups that we have done show that the public

thinks of a leader as someone who steps forward from the community and helps the community solve a problem, not one that dominates that issue.

In this case, the United States has the skills, the resources and

the world responsibility to step forward, not to take over this issue,

80

but to help the world community come together to solve it. Mr.

Chairman, you have talked recently about the importance of engagement, and I think this is a classic example of where this is an

issue that can only be solved by global cooperation and engagement, but it is one that we, by stepping forward, can help shape

tremendously. And we have a lot of the resources and skills to be

able to do that.

Now, let me just say a word about where this pandemic is going.

We heard a lot about that earlier in the hearing. Let me just say

that one thing we see over the next 5 years is that this issue is

clearly going global. It is concentrated now heavily in Africa. Secretary Thompson talked about the Caribbean. We know it is

spreading rapidly, as Dr. Piot said, in Eastern Europe. It is in

China. It is in India, et cetera. And while these situations are different and have to be addressed differently, as this issue becomes

more global, the issues become more global. I think we will see

over the next 5 years an even deeper and perhaps more contentious

debate over questions of access, questions of resources, poor versus

rich, prevention versus treatment, and this could become one of the

most divisive and contentious debates of the 21st century. We must

anticipate that debate and begin now to try to resolve those issues.

There is, it seems to me, in this area a danger of being overwhelmed by the problem. That is, we hear how incurable it is, how

many deaths have taken place, et cetera. I think it is also very important, as Dr. Piot said, that we realize that we have an opportunity to address this problem, contain it, and bring it under control.

When I was in South Africa last summer, one of the members of

the Anglo-American Corporation that leads an AIDS program said

he always starts his presentations in South Africa by saying that

75 to 80 percent of South Africans are HIV-free and that this is a

problem that they can contain and address. I think we have to look

at it that way as well, that if we take the steps needed, we can

in the next 5 years make a tremendous impact on this problem.

If we have a 5-year strategic plan, we should be able by 2007 to

get to a situation where the pandemic has reached a turning point

in its history, where the spread of infection has greatly diminished,

where it has dropped significantly in a number of countries, and

where we have far more agreement on the kinds of interventions

and steps that need to be taken.

Now, to get there in 5 years, we need to do a number of things,

and they have to be started now in order to get there in 5 years.

Prevention, of course, is as people have talked about, absolutely

critical if the rate of infection is going to be stabilized and reduced.

And this means putting in place national interventions that overcome ignorance and myth and alter the behavior of high-risk populations.

Second, the U.S. will have had to contribute to the building of

health infrastructures throughout the developing countries, and I

want to come back to that in terms of resources.

Third, as has been mentioned already, it is going to be extremely

important to support the education and other programs to enhance

the ability of women to play an important role in containing this

disease.

81

Fourth, we need to address the questions of orphans and have

in place programs that enable communities to take care of this very

large problem on the horizon.

Now, coming to resources, which you, Mr. Chairman, talked

about greatly—and you notice that Dr. Piot indicated a rising requirement, and I think this is very clearly going to be needed. We

know that right now this year, according to the testimony, there

will be somewhere around $2 billion available this year for addressing this problem. By the end of the 5 years, we should be at the

$7 billion to $8 billion a year level, and we need to start planning

for that and how to get there.

But let me emphasize that none of the additional resources for

HIV and AIDS should come from current and future programs

aimed at poverty alleviation. That would be self-defeating. If these

countries remain poor, they will be unable to deal with or sustain

any of the programs we put into place over the next 5 years. Moreover, poverty not only aggravates the problem, it poses terrible

choices for these countries. A South African official said to me, yes,

we can go forward and offer antiretrovirals to all the people affected by HIV and AIDS, but what about the people dying today

of cholera because they do not have access to clean water? That

kind of issue has to be addressed concurrently with our efforts on

HIV/AIDS. So, the poverty alleviation programs cannot suffer as

we increase the resources for HIV/AIDS.

Now, the question of access, the question of access to drugs and

care is, as already has been indicated, one of the most difficult

issues. There has been a lot of progress on this. There have been

steps by the pharmaceutical companies themselves to provide

drugs at greater prices. There are organizational programs that Dr.

Piot mentioned. But we still have a long way to go, and one of the

issues that concerns countries who are faced with this problem is

how sustainable are these programs that are now being put into

place.

In South Africa, one of the things that concerns the government

most is, if they start down this path of promising treatment to everyone living with HIV/AIDS, will the price reductions, will the

support be there 5 years from now, 10 years from now to enable

them to continue those programs? Of course, it would be a political

disaster if, having started down that path, they suddenly found

that the programs could not be sustained. In the next 5 years, we

need to have the answers to that and we need to have the institutions and the arrangements in place. I might add those arrangements must be such that they keep the pharmaceutical companies

in the game in the investment in research and the development of

new drugs and treatments, et cetera.

The CHAIRMAN. If you get that right, you will win the Nobel

Peace Prize.

Ambassador LYMAN. Well, I tend to be optimistic because there

has been a lot of progress. I think there is an interest in the industry on this front, and I think that it is possible to do those things.

Now, one other aspect that has only been touched on here which

has to be part of the 5-year effort, and that is to address the problem of HIV in the military establishments in developing countries.

It is having a major impact on peacekeeping, on the options for

82

peacekeeping, and we certainly do not want peacekeeping contributing to the problem. So, that has to be built into it as well.

There are a number of other steps that we can build into this 5-

year plan, but the point that we would like to make is that the

time is ripe for having a clear-cut, multi-sector 5-year strategy,

that we can start not just dealing with it annually, but know that

these are steps toward a 5-year program that we are confident at

the end of the 5 years we can say we have got a real handle on

this problem. I think now we have enough knowledge, we have

growing awareness, we have the skills to be able to achieve that.

Thank you very much.

[The prepared statement of Ambassador Lyman follows:]

PREPARED STATEMENT OF AMB. PRINCETON LYMAN, EXECUTIVE DIRECTOR, GLOBAL

INTERDEPENDENCE INITIATIVE, THE ASPEN INSTITUTE, ON BEHALF OF THE CSIS

HIV/AIDS TASK FORCE

INTRODUCTION

Mr. Chairman, I am grateful for the opportunity to appear here today, and commend you and other members of the Senate Committee on Foreign Relations for focusing on the global HIV/AIDS pandemic, a subject of profound urgency to U.S. foreign policy stakes.

I have the fortune of having just returned from a two-week visit to South Africa,

where I witnessed firsthand the intense, combative debate there over national priorities, in the face of a pandemic that directly touches every family in that society

and that threatens an entire generation. South Africa, like other acutely affected

countries in Africa and elsewhere, is truly in the midst of a complex and painful

national emergency that will be with it—and with us, by extension—for the next

few decades. From where we sit, it is difficult to grasp the urgency, magnitude and

innate controversy of what South Africans and others confront on a daily basis.

Also, I am a member of the international supervisory panel overseeing the evaluation of the first five years of the UNAIDS program.

I am here today however on behalf of the Center for Strategic and International

Studies’ Task Force on HIV/AIDS. The CSIS Task Force is a two-year effort, funded

by the Gates and Catherine Marron Foundations, intended to strengthen U.S. international leadership on HIV/AIDS. I am grateful to Senators William Frist and John

Kerry for agreeing to co-chair the Task Force.

Today, I will concentrate my testimony on how we might best design a five-year

approach to battling HIV/AIDS. I and J. Stephen Morrison, Director of the overall

CSIS Task Force, co-chair a working committee charged with looking into this question.

Such an approach will require a strategic vision that looks far beyond immediate

responses. It will demand sustained U.S. global leadership, a reliable grasp of how

the pandemic will likely evolve in coming years, and feasible, prioritized mediumrange goals. To build support at the popular level and among foreign policy experts,

this vision should also draw systematically upon the American people’s growing

awareness of the pandemic and their deepening well of support for a substantial

U.S. commitment.

In this context, and because it is such an important element in any such strategy,

I wish to discuss how the international debate over intellectual property rights and

affordable access to essential medicines has changed in the past year. Several recent

developments now focus our attention particularly upon sustainment of access:

through more reliable financing, greater transparency in global pricing, and

strengthened infrastructure.

LOOKING FIVE YEARS OUT

In the 1990s, ad hoc, stove-piped responses could not keep pace with the powerful,

swift momentum of HIV/AIDS. We now recognize that combating HIV/AIDS requires attention not only to health, but also economic, social and cultural factors.

Recent increases in U.S. high-level attention and resource commitments have

achieved significant gains and brought greater coherence to U.S. efforts, and encouraged others to do more. In its first year, the Bush administration showed sustained

leadership, even in the aftermath of September 11. It established the joint task force

on HIV/AIDS, co-chaired by Secretaries Powell and Thompson, assembled a strong

83

interagency team of experts, raised aggregate international spending levels on HIV/

AIDS to over $800 million in this fiscal year, and contributed substantially, both politically and financially, to the establishment of the Global Fund to Fight AIDS, TB

and Malaria.

These commendable steps reflect the deepening awareness, among our leaders

and the American public, that the AIDS pandemic threatens an unprecedented

moral, human, societal and economic catastrophe, and that it demands an unprecedented mobilisation that will stretch beyond this generation. Secretary of State Powell captured this reality very succinctly when he stated earlier this year: ‘‘I know

of no enemy in war more . . . vicious than AIDS, an enemy that poses a clear and

present danger to the world.’’ The risk remains, however, that fatigue or complacency with existing efforts may

set in.

If the international community is to assert effective authority over the pandemic

in coming years, the United States, in concert with partner governments, international organisations and others, will need a long-term, strategic, multi-sectoral,

and highly collaborative approach that steadily enlarges the pool of resources, with

a focus on clear, achievable priorities. To strengthen consensus and clarity of purpose, the Bush administration needs to join with Congress, on an urgent basis, in

forging an ambitious multi-year plan of action. That plan should spell out clearly

how U.S. leadership will be deployed strategically over the next several years to

build on recent momentum.

The realisation of the need for a long-term strategic international mobilisation

motivated broad endorsement of the detailed Declaration of Commitment on HIV/

AIDS issued at the UN General Assembly Special Session on AIDS (UNGASS) in

June 2001. It prompted the World Health Organization to launch the WHO Commission on Macroeconomics and Health, charged with analyzing the linkage between infectious diseases and economic productivity and proposing a multi-year plan

of action to redress weak health infrastructures in developing countries. UNDP has

subsequently committed itself to a broad based approach in all its country programs

that links health, development and political action to stem the pandemic. UNGASS

finally inspired the intensive international efforts that launched in early 2002 the

Global Fund to Fight AIDS, TB and Malaria, first endorsed at the UNGASS in

June. (The CSIS Task Force has also today released a briefing paper on the Global

Fund that is available at this hearing in hard copies and accessible in electronic

form through the CSIS web site.)

No less important, in the aftermath of September 11, an additional, powerful factor entered the debate over the HIV/AIDS pandemic: the awareness that runaway

infectious diseases, accompanied by and contributing to broken states and damaged

economies, are generating desperation and rising criminality. If we are to sustain

an anti-terrorist coalition, we cannot afford a lackluster response to the threat that

HIV/AIDS and related problems pose to developing societies.

THE CRITICAL IMPORTANCE OF U.S. LEADERSHIP

Over the next five years and beyond, global outcomes in battling the HIV/AIDS

pandemic will hinge, to an overwhelming degree, on U.S. leadership. Leadership

means using our strengths, our economic resources, and our skills to enable and empower the world community working together to combat this disease. The U.S. role

is critical for several reasons:

The U.S. plays a leading role in the international policy dialogue on HIV/AIDS

and related infectious diseases—in the G–8, the UN Security Council, deliberations

on the newly formed Global Fund to fight against AIDS, TB and Malaria, and elsewhere.

The U.S. is the preeminent force in global scientific research and the development

of new medical technologies.

The U.S. funds half of the worldwide programmatic response to HIV/AIDS and related diseases, in the areas of prevention, care and treatment.

Washington is the best positioned of any power to move international trade policy

to promote enhanced access to affordable medications.

So too, Washington is the best positioned power to link international debt relief

and other poverty-alleviation programs to heightened local investment in public

health interventions.

In exercising its leadership over the next five years, the United States should concentrate its efforts in three priority areas:

1. Expand existing U.S. strengths

The United States should consciously build upon its core strengths. These include

its leading role on global health issues; its record of appropriating an ample conVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00087 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
84

tribution to global funding; its vast institutional expertise in public health policy;

its long developmental experience in strengthening local infrastructure in resource

poor setting; and its predominant scientific research and development capacities

across public, educational, philanthropic and corporate sectors.

A key challenge is ensuring that there is coherence and effective coordination of

U.S. efforts, given the range and rising number of agencies operating overseas. Increasingly, there is overlap and duplication of effort, and it is frequently difficult

to identify who at a senior level position is actually in charge of the overall U.S.

campaign.

A related, pressing issue is which agency will carry lead responsibility in training

skilled medical personnel to address the critical personnel shortfalls in acutely affected countries. If that role is to be filled by the agency within HHS responsible

for such training, the Health Resources and Services Administration (HRSA), Congress will need to act quickly to provide it the legal mandate and funding to meet

this requirement.

The Joint Task Force can, and should, pursue these issues on an urgent basis.

2. Build key bilateral relationships

Modeled upon creative new public/private partnerships in Botswana, Uganda and

elsewhere, the United States should give priority to forging new programmatic partnerships with institutions, public and private, in acutely affected countries. These

partnerships should focus not only on HIV/AIDS assistance, but also trade and investment initiatives that will address poverty and weak infrastructure.

Integral to the success of those partnerships will be a new emphasis in U.S. diplomacy, at the country level, on battling global infectious diseases. That calls for

mainstreaming, and elevating within the foreign policy establishment, public health

professionals. The State Department has taken an important step in this direction

by creating the Office of International Health and Science, headed by Deputy Assistant Secretary Dr. Jack Chow. Equally important will be systematically integrating

America’s non-governmental organisations into U.S. programs and policy consultations.

3. Consolidate global coordination

The United States will need to act in close concert with—and leverage ample, focused contributions from—UN agencies, the World Bank, major foundations, corporations, and other bilateral donors. It should work to develop an international

steering committee on HIV/AIDS to ensure proper coordination and division of responsibilities between international donors, the Global Fund, UNAIDS, and bilateral programs—limiting duplication and achieving an appropriate balance between

research, prevention, treatment, and care.

The U.S. role will neither be to dominate, nor carry a disproportionate share of

responsibility. The essence of its leadership will be to rise to the task of mobilizing

the world community to better address this highly fluid, dynamic and complex pandemic. In practice, that means the U.S. will need to assign a far higher priority to

forging greater conceptual integration and coordination among the far-flung agencies committed to battling the pandemic, both within the United States and internationally.

STRONG SUPPORT FROM THE AMERICAN PEOPLE

This is a program that will receive strong support from the American people. Indeed the public will expect strong leadership by the Government in this area. The

American public and American foreign policy elites now exhibit a surprisingly high

knowledge of the HIV/AIDS pandemic, high levels of concern, and considerable support for substantial engagement overseas to combat the pandemic. Americans not

only strongly support U.S. leadership but also are open to new, more robust initiatives from American leaders.

This dramatic shift from the opinion environment of the late 1990s is the core

finding of a recently completed survey of popular and foreign policy expert opinion,

that was conducted to inform the work of the CSIS Task Force. The survey was carried out by Public Opinion Strategies and Greenberg Quinlan Rosner Research, generously funded through the UN Foundation/Better World Foundation. Those surveyed were particularly responsive to information on the scope and gravity of the

pandemic, its impact upon children, exhortations from Secretary Powell, and evidence that prevention and education programs are achieving concrete results.

TRACKING THE PANDEMIC

A U.S. multi-year plan should be informed by how the pandemic will evolve in

the next five years.

85

First, in the next five years the pandemic will have become globalized and will

be seen by world leaders as such.

The pandemic’s epicenter will remain in Africa, where heightened attention will

be paid to its course in Ethiopia, other areas of the Horn, and Nigeria. At the same

time, the pandemic will have extended its reach more deeply into China, Russia,

other states of the former Soviet Union, India, and the Caribbean states of Haiti,

Dominican Republic and Jamaica.

Second, we will see regionally differentiated approaches.

Africa will struggle overwhelmingly with acute constraints on access to health

services, borne of insufficient financing, weak infrastructure, and insufficient

trained health personnel. Young women and infants will bear the highest vulnerability, while millions of newly orphaned children will also attract significant attention. A handful of African states will likely dominate, intellectually, programmatically, and scientifically:Uganda, Botswana, Senegal, and Ivory Coast. Nigeria,

South Africa and Kenya, if they can overcome respective formidable internal barriers to effective action, could each quickly advance ambitious national programs

and establish prominent continental positions for themselves.

In Asia, the central preoccupation will be stemming at an early point the

pandemic’s spread. Strategies will vary widely.

In China, the focus will be upon mobilizing the inherited central command state

and newly emergent, scattered private medical enterprises to combat China’s deep

social stigma and contain four sub-epidemics: rural blood markets; medical re-use

of syringes; injecting drug use; and prostitution. Already, as new infections spread

into the general population, the Chinese government is coming under intensive pressure to institute new, nationwide public health campaign. By 2007, that campaign

will be fully operational.

In Thailand and Cambodia, the focus will be upon consolidating solid, state-led

gains in reversing infection rates.

In India, the central challenge will be circumventing its dense federal and statelevel bureaucracies, along with social and cultural barriers, in time to implement

meaningful programs before infection rates mushroom. By 2007, the pandemic will

have moved beyond the current six focal states to affect significantly virtually every

state.

In Russia and former Soviet states, the priority challenge will be overcoming the

collapse of the Soviet-era health infrastructure, in the midst of weak economies, and

altering high-risk behaviour among pariah sub-populations: of prisoners, prostitutes

and injecting drug users. HIV is poised to break out of these sub-populations; hence

the urgent need for a public education/prevention campaign in Russia and Ukraine.

Third, the struggle between the pandemic and efforts to control it will have generated mixed results at the country level. In many places, the disease will continue

to out distance local and international responses. In many other places, however,

determined, smart interventions will have begun to tame the pandemic.

In this context, individual country responses will inexorably have become increasingly differentiated.

Several countries will have steadily distinguished themselves and thereby attracted a major share of new resource flows: those which demonstrate strong leadership and probity of national institutions; which make substantial budgetary commitments to health; and which aggressively build affordable access to medical products,

indigenous skilled medical talent and scientific research capacity.

Occupying a middle tier will be states that struggle to overcome confusion, financial weakness and internal resistance. They will benefit from expanded international assistance, but on a comparatively more cautionary, and conditioned basis.

A third tier of distressed, internally conflicted or otherwise broken states will likely find themselves further on the margins.

Fourth, despite these differentiations, as the pandemic spreads and deepens, global norms will have evolved towards universal demand for expanded access to treatment.

This will intensify a debate: over prevention versus treatment; equity in the allocation of treatment (rich versus poor; urban versus rural); and the sustainability of

antiretroviral regimes and palliative care in resource poor countries. This debate

could become one of the most contentious and divisive of the 21st century unless

we act now to address it and plan for its resolution.

THE EMERGENT AGENDA ON AFFORDABLE ACCESS

Because this debate will become so important, it is relevant to examine in more

detail the direction of the debate on this issue so far, because it points to promising

ways by which it can be resolved.

86

In the past two years, there have been several major developments that have

broadened the landscape of debate over how best to promote affordable access to essential medicines by poor countries acutely affected by HIV/AIDS and related infectious disease.

First, the prices of many essential drugs have fallen radically.

The WHO Accelerated Access Initiative, begun in mid-2000, has brought now 70

countries into discussions with five pharmaceutical companies and provided enhanced technical expertise in determining which drugs are most appropriate. Negotiated and unilateral prices reductions, along with increased availability of some

new generic drugs, have reduced prices by as much as 90%, more in some instances.

Developing countries remain concerned that these price outs may last only for a

fixed period. Moreover, even at reduced prices, many of these drugs are still not affordable among the poorest countries: some expanded financing mechanism will be

required, along with concerted investment in basic infrastructure, if essential medicines are to be deliverable in the poorest settings.Second, the intellectual property

rights debate has shifted significantly.

At the Doha world trade talks in November 2001, trade ministers agreed that intellectual property protection is not and should not be a barrier to access. They also

agreed that the poorest developing countries will have no patent obligations until

2016; that means, in effect, that there are no legal arguments in those countries

over patents or compulsory licenses.

Related to these developments, one recent study has shown that most essential

drugs are not patented in the poorest countries (See Amir Attaran, ‘‘Do Patents for

Antiretroviral Drugs Constrain Access to AIDS Treatment in Africa?’’ JAMA, 286,

pp. 1886–1892, October 17, 2001). Also during 2001, litigation actions by pharmaceutical companies to enforce patent protection in South Africa and Brazil were

dropped in the face of intense public and media criticism, and in both countries cooperative arrangements between the companies and the governments are being developed to provide adequate access.

Third, the Global Fund to Fight Against AIDS,TB and Malaria, will soon launch

its efforts in April when it will respond to the first set of country funding proposals.

In 2001, the Fund will have up to $700 million to disburse, some of it on a multiyear basis. An estimated 80% will go to countries in Africa. At least an equal

amount will be available in 2002, perhaps more.

The Fund is uniquely well positioned to leverage the resources at its disposal to

improve country-level coordination, and to assist developing countries to develop the

technical capacity to refine their programs and negotiate most effectively with large

international and corporate entities to strengthen their affordable access. Most obviously, the Fund is will positioned to press for far greater transparency and consistency in global pricing of essential medicines.

Fourth, the WHO Commission on Macroeconomic and Health completed its major

work at the end of 2001. The committee headed by Dr. Richard Feachem developed

a pragmatic framework for action, by ‘‘the pharmaceutical industry (both patent

holders and generic producers) to agree jointly to guidelines for pricing and licensing

of production for low income markets. The guidelines would provide for transparent

mechanisms of differential pricing that would target low-income countries.’’ (page

89) This proposal, which envisions a set of reciprocal obligations between industry

and poor countries, is now in need of a plan to operationalize it. The Bush administration’s Joint Task Force should make that a priority for 2002 and beyond.

Fifth are the emergent public-private partnerships now a conspicuous part of national efforts in Botswana and Uganda.

Nevertheless, important issues remain. In the next few years there will be continued debate over aspects of TRIPS, most notably rules governing parallel imports.

But at the same time far greater attention will be paid to the sustairiability of initiatives intended to deliver essential medicines at affordable costs. This is one of the

principal issues that has troubled the South African Government and has inhibited

that Government’s willingness to make clear-out policy decisions that are desperately needed.

So too, much urgent work will proceed on how best to balance complex, competing

demands (how to block transmission from mother to child, while also oaring for an

infected mother), how to meet human skill and training requirements, how to measure the cost effectiveness of interventions, and how best to monitor and evaluate delivery systems. All of these issues must be addressed in a comprehensive response

to the HIV/AIDS crisis.

87

FEASIBLE, PRIORITIZED OBJECTIVES FOR 2002-2007

If the international community, with strong U.S. leadership acts forcefully now

and throughout the next five years, we can stem this pandemic and avoid a major

world catastrophe. By 2007, we should be able and should commit ourselves to a

situation where the pandemic should have reached a turning point in its history.

The pandemic’s speed should be far better contained than it is today, prevalence

rates will have dropped significantly in several acutely affected areas, and efforts

to mitigate the pandemic’s impact on societies and economies will have begun to

achieve concrete results.

To achieve this set of goals, we envision U.S. programs and policies put in place

over the next five years organized around four priority areas:

1) Programmatic interventions

• Prevention is the mainstay, if in the next five years we are to see the rate of

new infections stabilized and reduced. Most importantly, that means putting in

place national interventions that overcome mass sero-ignorance and myths, and

alter the behaviour of high-risk populations. Cooperative efforts among governments, international organisations, NGOs, local communities, and religious

organisations, will have been fostered in every affected country.

• The U.S. will have contributed significantly to strengthening healthcare infrastructures in the most heavily impacted countries, increasing the availability of

treatment for opportunistic infections as well as direct HIV/AIDS treatment.

• The U.S. will also have given special attention to strengthening women’s organisations to provide women greater protection and a greater voice in prevention, treatment, and care of family members.

• To more adequately address the challenge of AIDS orphans, communities will

have also been strengthened with widespread assistance programs, scholarships, and other support services.

• For virtually every programmatic intervention, urgent training of skilled personnel will have been a top priority.

2) Bilateral and global resource mobilisation

• The U.S. will have helped leverage significant increases in funding, from multiple sources, that narrow the gap between supply and demand.

• In 2001, approximately $1.8 billion in external assistance worldwide went towards prevention, care and treatment in developing countries acutely affected

by HIV/AIDS, of which slightly less than half came from public and private

sources in the U.S.

• By 2007, that figure should have risen to the $7-8 billion range annually, with

aggregate U.S. contributions amounting to at least $3 billion per year. That

translates into a tripling of resources over the next five years, roughly the same

level of growth between 1997-2002.

• None of the resources for HIV/AIDS must come from current and future programs for development and poverty alleviation. Rather, these latter programs

should themselves be strengthened and increased because poverty alleviation

will have a major impact on the capacity of affected countries to address in a

sustained manner the many issues associated with this pandemic.

3) U.S. investment in research and technology

• The current potential of U.S. research efforts will have been realized and significant progress made on vaccine development and trials.

• The U.S. will have collaborated on and contributed to significant research on

social and cultural factors in every acutely affected country, enabling messages

on prevention, especially among youth, to have greater impact.

• U.S. health institutions will also be mobilized and effectively engaged in

strengthening the research and treatment capacities of the comparatively advanced healthcare infrastructures in Asia and CIS.

4) Concerted multilateral action

• The U.S. will have helped elaborate and strengthen a new global health architecture—centered on WHO, UNAIDS, and the Global Fund—that increases the

capacity and reliability of surveillance systems, creates greater coherence and

integration of responses, that mobilizes new financial flows, and that promotes

exchange of data and debate of emergent issues.

• To increase financial transparency and affordable access to treatment, appropriate pricing and distribution policies and programs will have been established

in all acutely affected countries, with a combination of private, host governVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00091 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
88

ment, and international financing as appropriate. These policies will have been

structured and financed in ways that assure universal access as well as continued private sector investment in new treatments and drugs.

• Major progress will have been made to control HIV/AIDS infections in international military establishments, preventing peacekeeping operations and other

international deployments from further contributing to the pandemic.

Only with this degree of commitment and action, beginning now, can the world

stem this crisis. But the good news is that if we so act now, we can do it and leave

the next generation safe from this plague and its dire consequences.

The CHAIRMAN. Thank you.

Let me say to the other two witnesses, who I would like to go

to right away, I am going to be necessarily absent for a few minutes here, and I am not sure, since we are to host the SecretaryGeneral at 3 o’clock—this all got backed up because of the late

start with the five votes. But I will try to come back between now

and 3:00 to ask questions, but Senator Frist has kindly suggested

he would be able to—I am sure he is able. He is willing to continue

and bring this hearing to a close in the event I cannot get back.

I would like to suggest that I have a number of questions that I

would like to submit to you in the event I cannot get back. My

leaving is not a lack of interest or disrespect. It is a scheduling dilemma that I do not know quite how to resolve at the moment except with the help of Dr. Frist.

I would like to proceed with you, Doctor, now with your testimony. Again, I apologize for not being here. I will read your testimony, but I apologize for not being here while you testify. Please

proceed.

STATEMENT OF DR. SUNANDA RAY, DIRECTOR, SOUTHERN AFRICA AIDS INFORMATION DISSEMINATION SERVICE,

HARARE, ZIMBABWE

Dr. RAY. Thank you very much to the Senator, as he leaves, but

to the committee as well for inviting me to come and make a testimony today.

I should just say again my name is Sunanda Ray. I am the Director of SAfAIDS which is a southern Africa information dissemination service for HIV and AIDS. It covers the SADC region essentially which includes Tanzania, but we have lots of links with East

Africa. So, sometimes we do things together, but in the main we

are trying to target the countries that actually are hardest hit by

HIV which have been less referred to here today. Botswana,

Zimbabwe, Swaziland, all have very high HIV rates. South Africa

has the largest number of people with HIV and the most rapid incidence and Zambia, Malawi, Mozambique also have major problems,

though Zambia has successes also that we can learn from.

I am going to speak today really from the basis of being a nongovernmental organization, and it was referred to earlier that the

NGO’s actually pick up a lot of the work that the government is

not able to do. And to some extent, NGO’s and civil society organizations are more flexible in what they can do. But in many ways,

they are also the least resourced depending on who their donors

and funders are.

One of the resources that is probably less used because of funding problems is a mushrooming number of civil society organizations, community-based organizations. And our plea to the comVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00092 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
89

mittee would be that you, along with other donors, look at how the

funding arrangements can be made more flexible so that a lot of

the innovative work that is coming from small organizations can be

considered, but recognizing that these organizations do not have

the infrastructure or the skills to actually fulfill the kinds of reporting requirements that are laid out by the donors.

Now, the way the donors usually respond to this is by asking a

bigger umbrella organization to, in a way, mentor the smaller organizations. We get asked to do this a lot, and what happens as a

result is it is like saying if something is good, let us throw more

work at it until people who are already overcommitted completely

drown in the work. And that creates a lot of problems because we

do not have the capacity to absorb the work of lots of small organizations.

Our answer to that would be that we would like much more investment in the kinds of skills and capacity building that has been

referred to, but specifically within small organizations to help these

organizations to do the work that they are good at but also to fulfill

fairly basic reporting requirements, that they should not be asked

to fill in these huge forms that they are asked to do, but also that

larger organizations can also have investment as trainers of those

organizations.

This tends to be a whole area that is neglected. It is either there

that people have the management capacity or it is not. As much

as we need to train doctors in how to treat people with ARV’s, we

need to train managers within organizations in how to properly

manage them and how to account for the money that they are

given, but also as part of the monitoring and evaluation, how they

should be looking at evaluating how well they are doing because

that is a resource that many developing countries do not have.

That is the first thing.

Then the second thing is that we are asking for more consideration on time frames. There is a contradiction here. On one hand,

we want HIV to be treated as the emergency that it is. If we had

the same numbers of people dying in a terrorist attack or in a cholera epidemic or a flood, there would be an immediate emergency

response, a multi-sectoral response from the donors getting together and planning how they were going to respond to this. I

would argue that we really need that level intervention right now.

There are areas of southern Africa where one in three women coming into an antenatal clinic is HIV-positive. That is an emergency.

This is usually a young woman, maybe in her first or second pregnancy. That is an emergency.

At the same time, we have to recognize that this is also a longterm development problem. So, we need plans that go beyond the

2- to 3-year funding plans that are made out. People need to be

able to plan for the next 10 years how they are going to manage

their programs and they need support in doing that from the donors. It is very difficult to hire staff, who are of the caliber that

are required to manage these programs, and make a commitment

to them on a 2- or 3-year basis. Usually as soon at the UN needs

to fill a position, that person will leave to get a higher paid job,

even if they are personally committed to the work that they are

doing in an NGO. We need to be able to give people commitments

90

that they will be employed for much longer, and we need to develop

plans which involve the work that they are doing in communities.

So, the length of time and the basis on which things get treated

as an emergency and development need to be reviewed by all the

donors, not just by USAID.

And the third issue is this issue of grants. We have heard about

huge amounts of money being discussed here. And the people living

with HIV that we are in contact with on a daily basis often say to

us, where is all this money? Because we do not see it. I might say

to them, well, we see a little bit of it. And they will say, well, we

do not see any of it. Often the issue is that they believe that they

are the ones who are living with the problem, but there has been

a huge industry that has been developed out of AIDS and they

have very little part of that cake.

So, we would like to see more of the money that is allocated to

HIV and AIDS actually spent in the countries which have the problem and, in particular, that are hardest hit.

A typical case is where you will get a donor coming into a country and they want to do some work. They will set up a tendering

process whereby organizations have to tender for money. If you

take southern Africa, it will be the same organizations that are

asked to bid on these huge amounts of money, and usually we do

not have the capacity to do it. So, then outside organizations win

the contract, which means that essentially we are paying for salaries in Europe or in the U.S.

The same thing happens when consultants come out. Their salaries and all the other structures that support them are earning the

money usually in their host countries.

And we want more of that money to be spent in our countries.

But we acknowledge that we do not yet have the level of skills to

perform the same kinds of duties. So, what we are asking for is

that each of those consultants, when they come, they come as trainers. So, for instance, when CDC sends people out to do surveillance

or epidemiological reviews or any of the programs they do, part of

their commitment has to be to train local people. Now, if they cannot train local people because of government issues, then they

should look for alternative structures that they can train people.

And we have got good partnerships. In Zimbabwe, we have a

good relationship with the CDC group there and with the USAID

group. And there are ways whereby their skills can be transferred

to local people, even if it is just straightforward analytical skills.

It needs a mind set which says that we are here to support local

people, rather than saying we are coming in to do the job, which

is a little bit what I have been hearing at the presentations today.

People are saying we are doing this, we are doing that. Actually

what we are saying is we want to do it and we want you to do

skills transfer. We want to learn from you how to do it, but we

want you to leave knowing that there are people here who can take

over and do the same work. It is solidarity rather than patronage

I think is perhaps the way of looking at it.

My last point is that all of these structures that we have been

talking about and all of the programs that we know are effective

should all be linking together and they all require much, much

more investment in public health infrastructure. So, for instance,

91

to spell it out, we are talking about the Global Health Fund looking

at TB, HIV, and malaria, and these are three programs that traditionally have been done in a vertical way—TB and malaria anyway—and that they do not link up together enough. That means

that there is an awful lot of opportunity that is lost in trying to

get the best benefit for each of those programs.

If you take voluntary counseling and testing, linking that with

TB programs means that every person who goes through a VCT

center who is told that they are positive should be screened by the

person giving them the results symptomatically to see whether

they also have TB, not saying to them, okay, for the screening, you

have to go to another center, because the chances are they do not

have transport money to go to both places.

If they get through the TB screening, they should come out

knowing that they are at risk of TB and how they can protect

themselves or how they can know whether they need further referral.

Similarly, people who go through a TB screening service or a TB

case finding service should also know about the link with HIV and

should be referred to VCT, not just them but their families as well.

So that then those linkages are made and the messages are repeated often about the risks of HIV and the risks of TB.

The issue about parent-to-child transmission is a very hot one.

We insist on calling it parent-to-child not mother-to-child because

it is the only way of drawing in men to the problem. When people

talk about mother-to-child transmission, often the responsibility of

men, both in preventing infection but also in helping cope with it,

is ignored. You find that when you are talking to groups of people,

they actually assume that this is a woman’s problem and that they

do not have anything to do with it. But if you can get men to attend one antenatal care clinic, one clinic session with their partners, there is a whole range of activities that should open up to

both the man and woman, and testing is just part of that, bearing

in mind what the earlier speaker said, that 70 percent of the

women coming through antenatal care will be negative, and they

need to know how to protect themselves. But they do not have

power to protect themselves. They rely on their partner’s cooperation. So, the partners need to know how to protect their families.

And men do not like getting information from their wives or their

girlfriends or their partners. They like getting it firsthand usually

from professionals.

So, having a whole system that encourages men to come in

means that you have to have the resources to be able to provide

all those services. You cannot expect overworked health staff to

provide all of these functions without any additional investment,

and this is where we are proposing that we have to get back to that

concept of good quality comprehensive health services where all the

health staff are trained in how to deal with all these issues, not

necessarily to become full-fledged counselors, but to know when the

opportunities arise to be able to provide that advice.

I think I better stop because I know we are short of time. But

my last point is that we have to remember that poverty underlies

all of this. The reason why young girls are so at risk of infection,

even when they know how they get infected, even when they know

92

how to protect themselves, is because they are usually using sex as

a way of getting out of poverty. Until that changes, they will continue to be at risk.

Thank you.

[The prepared statement of Dr. Ray follows:]

PREPARED STATEMENT OF DR. SUNANDA RAY, DIRECTOR OF SOUTHERN AFRICA HIV/

AIDS INFORMATION DISSEMINATION SERVICE [SAFAIDS]

HIV/AIDS: PREVENTION, CARE, TREATMENT AND IMPACT MITIGATION NEEDS IN

SOUTHERN AFRICA

Summary

The southern Africa region is confronted by a major catastrophe in the form of

an HIV epidemic that has not yet spent its force. We are facing 50% of our current

15 year old cohort being dead before age 50 mainly through AIDS related mortality.

The burden of HIV is greatest for the poorest people, felt hardest at household level,

with families staggering to cope with loss of their main income earners and food

producers dying of AIDS while elders are looking after increasing numbers of orphans and vulnerable children. Children themselves are now becoming the carers,

giving up aspirations of education and employment to do so. This is happening at

a time when many of our countries are in economic difficulties and we do not have

the resources to adequately respond to this epidemic.

Many interventions are known to be effective in prevention of HIV transmission,

treatment and care of those affected in developing countries. Some are:

• provision of voluntary confidential counselling and testing facilities, particularly

targeting young people;

• prevention of parent-to-child transmission through antenatal clinic advice, testing and provision of ARVs to mothers and infants, as well as infant feeding

guidance;

• a management and control of sexually transmitted infections;

• male and female condom promotion;

• peer facilitation with young people, sex workers, mobile populations such as

truck drivers;

• youth friendly sexual health services;

• community based care for people living with AIDS;

• integrated comprehensive tuberculosis and HIV care.

All these programmes require good quality public health infrastructure extending

from hospitals, health centres and clinic to community based workers and the communities themselves, the so-called continuum of care approach. This is a major area

for investment from donors: in training and staff development; maintaining standards of care; reliability of commodities and supplies of drugs, male and female

condoms; home care materials; destigmatisation of HIV; workplace policies against

discrimination; information exchange especially in good practices and lessons learnt.

Integration and interlinkages between programmes such as family planning,

antenatal care, STI control, infant feeding, TB management, home based care and

VCT provide the best opportunity for maximum gain in breaking down the paralyzing stigma and denial that haunt our programmes. Each sector reinforces the

messages promoted in support and care, maximizes the efforts of staff, community

workers and volunteers, with structured referral between services to avoid duplication and repetition. All this activity will need a good overall national strategic

framework to pull it together, the development of which is a major priority for each

government and will require donor input and expertise to facilitate the process.

Donors need to become more flexible and responsive to the needs of non-governmental organisations, community groups and support groups in providing funding

in small chunks to enable them to do what they are good at without getting overwhelmed with administration and accounting. Larger organisations would also benefit from training and organisation development in managerial skills so that they

can oversee and support these smaller community groups in their activities. Regional investment in drugs and condom manufacture would provide employment and

avoid transfer of valuable scarce resources to industrialized countries. Similarly, investment in local expertise would circumvent paying salaries in rich countries for

work done in the region. These solutions require a longer time-frame than most donors plan for, probably 10-20 years to properly achieve the goals and benefits set

out in strategic planning.

93

INTRODUCTION

Globally, by the end of 2001, 40 million people were living with HIV, with 28.1

million, or 70%, from sub-Saharan Africa. In addition 21.8 million people had died

of AIDS, with 19 million, or 87%, coming from sub-Saharan Africa. The highest

number of new infections is still in Southern Africa, which has 50% of Africa’s cases

and the world’s nine most affected countries. Illnesses and deaths from AIDS will

continue to rise for many more years, even when HIV incidence has stabilized or

begun to drop. Consequently life expectancy has been drastically lowered, with Swaziland and Zimbabwe reduced to 30–40 years by 2010 if current trends continue.

South Africa has an estimated 20% of adults infected with HIV, an increase from

13% two years ago. This translates into 4.2 million people living with HIV/AIDS,

the highest individual country total in the world. The two countries in the region

with the highest population percentages are Botswana and Zimbabwe, with estimates of 36% and 35% of adults infected respectively. In Botswana the prevalence

rate has increased to 46% among women aged 25-29. Health services are obviously

overwhelmed—an estimated 70% of Zimbabwean hospital bed occupancy is HIV related. In Malawi only 400 out of 900,000 persons with HIV receive antiretroviral

therapy: in the region ARV treatment is generally inaccessible due to extremely

high costs and spiralling poverty. The effect of HIV/AIDS on other sectors such as

education is enormous: in 1998 Zambia lost 1500 teachers, 70% of the new teachers

trained annually. In much of southern Africa half our 15-year old boys will be dead

before they reach age 50 years, with mortality mainly due to HIV-related causes

[UNAIDS].

Although these figures are very dramatic, there are some positive trends. For example UNAIDS reports that for the first time there are signs that the annual number of new infections may have stabilized in some parts of sub-Saharan Africa. In

Zambia, recent surveillance data suggest a drop in HIV incidence among young people aged 15-19 years in the two main towns of Ndola and Lusaka. Uganda has also

been notable in reducing HIV prevalence in young people as evidenced by antenatal

trends.

In order to encourage and build on these developments, HIV-related activities

have to concentrate more on targeting young men and women for prevention. Early

sexual debut and early marriage are risk factors for HIV for women, because of biological susceptibility during adolescence and because of the age gap between women

and men, whereby men would be in older age groups with higher HIV prevalence.

The best opportunity for significant prevention of infection is targeting young people

before the age of sexual debut, since it is easier to influence safer sex patterns from

the outset than change established patterns of behaviour in adults. Supporting

women in self-efficacy skills that enable them to refuse early sex provide better

chances that they will be able to negotiate for condom use later. Social and community norms that hinder prevention efforts, that encourage stigma and discrimination, have to be challenged. In addition, families living with AIDS need practical

and emotional support including caring for the carers. The HIV epidemic has exposed areas of gender inequity in all our countries that were already the basis for

poor health and inadequate social development in the past, which need addressing

even more urgently now. HIV, maternal mortality and sexually transmitted infections [STIs] are the greatest causes of women’s ill health, accounting for over 50%

of disease burden among women in southern Africa. By promoting understanding

of the long-term development impacts of the epidemic, we can stimulate more effective responses including tackling the poverty/HIV cycles whereby each makes the

other worse.

WHAT DO WE KNOW ABOUT WHAT IS EFFECTIVE IN PREVENTION AND TREATMENT

PROGRAMMES IN DEVELOPING COUNTRIES?

The response to HIV/AIDS includes three essential components;

• Prevention of new infection.

• Treatment and care of people living with HTV and AIDS.

• Mitigation of current and future social and economic impacts of the epidemic.

Key elements of prevention include what is known as the ‘‘abc’’ in southern Africa:

abstinence, be faithful and condom use. All of these depend on the ability of individuals to negotiate for these behaviours. The literature on gender dynamics permitting

or otherwise women and men to carry out these behaviours is extensive. A major

failing of previous HIV prevention programmes in the region is that there was

undue reliance on individual behaviour change without concurrent supportive

changes in societal norms and values, the so-called enabling environment. Now it

94

is clearer that community education and community behaviour change are essential

to support people to undertake all these protective behaviours.

In addition, condoms have to be accessible for those who want to use them. The

Thailand experience of the 100% condom campaign targeting sex workers and clients led to a reduction in new infections from 143,000 in 1991 to 20,000 in 2000.

In Cambodia new infections in sex workers dropped from 40% to 23% in 2000, with

sales of condoms climbing from 100,000 in 1994 to 11.5 million in 1998. If condoms

are available in sufficient quantities for those who want to use them, there can be

significant impact on STI/HIV transmission. Provision of male condoms per year by

donors in six countries of sub-Saharan Africa with the highest provision averaged

17 condoms per man aged 15-59. These countries were Botswana, South Africa,

Zimbabwe, Togo, Congo and Kenya. In South Africa, it is estimated that 84 condoms

per man aged 14-63 years would be required per year based on an average of 7 episodes of sex per month. Obviously, some would be more and some less, and some

men would not need to use condoms at all if they were with a steady partner. However, based on these statistics one billion condoms would be required for South Africa alone for men aged 15-59 years. The number of condoms distributed free by the

government rose from 6 million in 1994 to 198 million in 1999, still indicating a considerable condom gap in a country with rapidly growing HIV incidence. Locating

condom manufacture within the region [as is the case with East Asia] with suitable

quality control would make a substantial difference.

Other essential components of prevention are STI control and prevention of parent-to-child transmission [PTCT]. STI control requires reliable supplies of condoms

for prevention, drugs for syndromic management with laboratory back up for resistant cases. Prevention of PTCT requires access to good quality antenatal care, health

workers trained to provide advice, testing facilities. For women identified as HIV

positive, the options available for prevention of transmission to their infants are

Nevirapine or AZT given to mother and infant, caesarean section as method of delivery and advice on exclusive breastfeeding or exclusive artificial feeding [mixed feeding presenting the highest risk]. Most countries cannot afford to offer free formula

feeding and there is enormous stigma attached to being seen to bottle feed since this

labels the women as HIV positive. Nevirapine has been provided free to countries

with high prevalence but the above account shows that drug costs are a small part

of the overall infrastructure required to prevent PTCT. The benefits of PTCT programmes extend beyond prevention of infection to infants. Voluntary counselling

and testing [VCT] has been shown to provide motivation to individuals to stay negative or to seek support if they are positive. If antenatal care includes this process

of VCT in addition to public education about HIV, there is potential benefit at each

stage, particularly in informing women about the risks of HIV, how to protect themselves. With more discussion about HIV, there could be more openness leading to

potential benefits of destigmatisation in communities. Even where 30% of women attending antenatal clinics are HIV positive, the majority will be negative, and need

the opportunity to protect themselves. At present, there is so much fear surrounding

the presence of HIV, that many women assume they are HIV positive and lose opportunities to prevent infection. Where men are encouraged and motivated to attend

antenatal clinics with their partners, they may access advice and testing also, with

potential benefit to themselves and their families. One generalized intervention that

is being proposed is motivating men, without testing, to use condoms for a defined

period of time during their partner’s pregnancy and breastfeeding to avoid the higher risk of passing on infection during seroconversion. It is estimated that 5% of

women become positive during the year of their pregnancy and breastfeeding, probably because their husbands have had casual sex during that time.

For all these behaviours in prevention to be successful, they have to be promoted

within an environment that is supportive of protection, and with good quality health

service infrastructures in place. Apart from Botswana most PTCT programmes are

in the pilot stage, but are ready to be scaled up nationally. The main obstacle will

be the lack of trained staff to properly support women and their partners in making

decisions about their HIV status and their pregnancies.

As far as treatment and care are concerned, the problems in providing services

are even greater. The HIV epidemic has increased the burden of disease up to sevenfold increasing demand for public health care at the same time as spending on

health care has decreased in many countries in southern Africa. Most people with

AIDS are cared for at home by relatives who have very little formal support with

protective materials or emotional support. Many of these relatives will be themselves living with HIV, or caring for other children from parents who have died of

AIDS. Many of the carers are themselves children looking after dying parents. Most

support comes from NGOs or faith based organisations, rather than public health

services. These either do not have transport to do home visits, or are struggling to

95

cope with their inpatient load. They also do not have spare materials to provide in

home care. People dying of AIDS do not have basic analgesia to ease their pain, suffer from malnutrition because they have terrible mouth sores from fungal infections

and cannot swallow, do not have access to anti-diarrhoea drugs or drugs to stop

their vomiting. For many, therapy to ease opportunistic infections and pain are

higher priority than antiretroviral drugs. Although ARVs have made a major impact

on survival of people with HIV in industrialized countries, differences in life expectancy were already stark because of the difference in access to basic health services

and early treatment of opportunistic infections.

If cheaper sources of ARVs are made available, the infrastructure costs of provision must be factored into the costs, including costs of VCT and provision for

spouses and other HIV positive children. Activists and the medical profession alike

often overlook equity of provision when campaigning for ARVs. If public money is

spent on acquisition of ARVs with the support of donors, the best way of ensuring

equity is to channel the drugs through programmes such as prevention of PTCT so

that women attending antenatal care and found to be HIV positive, are prioritized

for treatment if appropriate. Their partners can also be drawn in through the provision of treatment which if accompanied by good quality VCT, would work towards

caring for affected families, linking them with support networks and advising them

on positive living and early treatment of infections. Tuberculosis programmes that

have good mechanisms already for registration of patients, with good follow up and

care, would be another appropriate means of identifying families for VCT and ARV

therapy while keeping equity of access foremost in priority. If these strategies are

not in place, ARV therapy will mainly be used to benefit the rich and influential

without safeguards for poorer people, especially those in rural areas.

WHERE SHOULD DONORS CHANNEL RESOURCES?

For the HIV epidemic to be adequately addressed, major investments are needed

on a crisis scale in public health sectors of countries in the southern Africa region.

This need is underscored in every aspect of prevention, treatment and care. In addition, recognizing that the impact of HIV is wider than the health field, and is greatly felt in all aspects of social and economic development, investment is also needed

in other sectors such as in education of young women and men, provision of further

education and employment possibilities, restructuring of social welfare to serve the

needs of families decimated by AIDS, in particular orphans and vulnerable children,

training of all levels of public sector workers in all these fields, to account for attrition due to ill health as well to cope with the increasing demands.

Interventions that are known to be effective have to move urgently from pilot

projects to national scaling up. The public and private sectors have to be prepared

for this, and linkages between the programmes maximized for greatest benefit. So

for instance, all VCT services should also provide basic symptomatic screening for

STIs and tuberculosis, with onward referral to services as appropriate. They should

also provide family planning advice to prevent unwanted pregnancies. Public health

services similarly should refer persons screened for TB to VCT in view of the linkage between TB and HTV. Family members should also be referred. For these referrals to be effective, STI, TB, family planning and VCT services need to drastically

intensify their advisory services, bringing up HIV with clients as much as possible,

especially to break down the denial and stigma patterns that have fostered the epidemic. In this prevention, treatment and care are closely intertwined, with intensive

promotion that the majority of people are negative and need to stay that way. Primary health care gains in many countries in southern Africa have been reversed

by the HIV epidemic. However, the developments that led to those gains have to

be urgently revitalized to link quality antenatal care, family planning, infant feeding, child health, syndromic STI management, TB control, support for home based

care and management of opportunistic infections in people living with AIDS under

the banner of comprehensive health care. Added to this will need reliable provision

of sufficient quantities of commodities such as male and female condoms, antibiotics,

pain relief, symptomatic treatment for HIV related illness including opportunistic

infections, and protective materials for home based care. This will be even more effective if coupled with public education so that health services are actively supported by their communities, with linkages with volunteers, faith institutions and

NGOs. All this activity will need a good overall national strategic framework to pull

it together, the development of which is a major priority for each government and

will require donor input and expertise to facilitate the process.

All these programmes need to give special attention to targeting young people.

Linkages with school health programmes, peer facilitation projects, media work with

young people, youth friendly clinics and advice centres, sports and educational enVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00099 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
96

tertainment programmes are various ways in which this can be achieved. More action research is needed on where young people get their information from, who they

respect as peer facilitators, what influences are successful in persuading them to

protect themselves, how they arrive at realistic decision making, and how to increase self efficacy for young women and men. The behaviour changes desired are

delay in sexual debut, consistent condom use, early attendance for STI treatment

and understanding the link between infertility and STIs at young ages, prevention

of young women treating sex as a commodity thereafter ending up as sex workers.

Donors have an additional role to play in providing flexible systems and mechanisms to support small-scale community development, local structures and

organisations. This is partly through funding but also through capacity building,

supporting information exchange and dissemination in accessible formats, supporting innovative methods of interactive information exchange such as through

media, email discussion fora, theater and performing arts. At SAfAIDS we do all

these things entirely through donor funding. In addition we link researchers with

organisations involved in implementation, so that research findings can inform the

design of programmes, provide feedback on research and implementation across

groups, and translate information found on the internet or e-mail discussions into

print formats such as newsletters and bulletins so that those without computer access can still be updated.

CRITICAL APPRAISAL OF U.S. BILATERAL ASSISTANCE EFFORTS

My main experience with U.S. assistance for HIV programmes is in Zimbabwe.

USAID has focused on several areas of proven effectiveness combined with operational research components to establish what works where the evidence is not so

clear. These programmes are:

• Social marketing programmes for high quality voluntary confidential counselling and testing [VCT] services through the private sector; this is mainly in

urban areas but provision of mobile outreach clinics for more rural areas is

being explored. These programmes particularly target young people.

• Social marketing of male and female condoms and oral contraceptives through

pharmacies and supermarkets. Procurement of condoms is done in conjunction

with the British Department of International Development [DFID].

• Support for the Zimbabwe National Family Planning Council [ZNFPC], in particular to train and upgrade community based distributors of oral contraceptives

so that they can provide other forms of sexual health advice.

• In conjunction with the U.S. Centres for Disease Control [CDC] programme in

Zimbabwe, there is support for monitoring the spread of HIV in Zimbabwe

through serological surveillance and a youth sexual health survey. They are also

embarking on a media programme targeting young people.

• Impact mitigation through orphan care, educational support for girls, microfinance projects targeting women, vulnerable groups such as street children and

farm workers.

• A policy and advocacy programme has just started which plans to provide support and grants for private sector and NGO initiatives to destigmatise HIV and

reduce discrimination such as through workplace policies, capacity building, lobbying parliamentarians, and use of media.

The main constraint we face in the NGO sector in the region related to U.S. funding for our projects is that the process of procuring funds is very bureaucratic and

cumbersome. In the words of one friend, big money is not always the answer if it

cannot be delivered in small enough chunks. There is little flexibility in the system

to make small grants to NGOs with good ideas but little absorptive capacity for

large amounts of money. A grant of 50,000 U.S.$ to support VCT activities in an

NGO involves the same arduous process as a grant of 20 times that amount. The

justification for this is in need for organisational accountability and financial accounting mechanisms. However, it means the funding cannot be used in ways that

are dynamic, responsive or empowering to community groups where the impact of

the HIV epidemic is felt the hardest and who have the least means to protect themselves.

Another problem is that the time scales for programme planning and funding are

short, sometimes 2 to 3 years. A much longer-term perspective is essential for strategic planning to achieve its goals, probably 10-20 years. The effects of HIV in communities will continue to be experienced for that long even if new infections are entirely prevented. At the same the urgency of the current HIV epidemic in southern

Africa has to be regarded and dealt with as a crisis rather than a chronic development issue, so that disbursement of funds are more quickly facilitated to multiple

97

sectors and groups working to ameliorate the impact. Some have called for

mobilisation of ‘‘war budgets’’ with all resources reoriented towards this effort.

TRAINING AND INFRASTRUCTURE NEEDS IN DEVELOPING COUNTRIES

Many training and infrastructure needs have been referred to in earlier sections

but it is worth emphasizing some needs in particular. At SAfAIDS we are often

asked to act as an umbrella body to smaller organisations to enable them to get

grants through us because we have the skills and accounting mechanisms to fulfill

donors reporting requirements. If we agreed with this, our attention would be divided between doing what our mission is, which is using information as a change

agent, and mentoring smaller organisations with varying capacity and ability to

carry out what their purpose is. There are not sufficient indigenous organisations

with the necessary skills and infrastructure to carry out this kind of mentoring because it is difficult to retain skilled staff within the NGO sector. For this reason

donors often commission international agencies to develop networks of partners to

carry out their work but the sad consequence is that valuable funds then go to pay

salaries in Britain, U.S. and Europe rather than investing in capacity building within the region. South Africa is one country that has private companies competing for

many of these contracts and we could make more of developing regional partnerships with them. One essential training need here is to build up managerial and

financial accounting capacity within small organisations so that they are better able

to report on the funds they receive, and among larger organisations so that they

can capacity build smaller organisations. Developing centres within universities to

carry out these functions would be another way to support training as well as skills

expansion, staff development and consultancy.

A major gap that has developed between rich and poor countries is access to computer skills and information technology, with the access this provides to updated information. Most secondary schools in the region do not have computers even when

they have access to electricity and phone lines, so students do not even have keyboard skills. Access to IT has been liberating in many circumstances. Many academics are now able to access medical and other health journals free on the internet

whereas they previously received print journals very late, if at all. Discussion fora

prior to conferences are often more interesting than the conference proceedings

themselves, and usually more democratic. The youth e-mail discussion forum for the

African Development Forum 2000 in Addis Ababa was a case in point. We provide

cyber training for small groups of NGOs that have access to email and internet but

do not know how to use them. This is an area that could develop rapidly with investment beyond what we can offer, taken up by major training in each country.

Email discussion groups in each country could enable the National AIDS Councils

to keep their partners and member organisations informed of grants, funding, activities as well as stimulate debate on various aspects of the crisis, such as how the

money is being spent! Other use of technology is that the rapid acquisition of cell

phones in the region has meant that setting up telephone helplines for the public

are now a possibility whereas in the past this only served urban elites.

Finally, there are major training needs for all levels of public sector workers related to HIV/AIDS, in health, education, social welfare, industry, agriculture and so

on. For health sector workers, training in provision of sensitive non-judgemental

sexual health services for all who walk in the door is crucial so that they do not

create barriers to uptake of services as often happens at present. In particular they

need training in how to provide youth friendly services in imaginative ways [such

as having peer facilitators working alongside them in clinics], how to encourage sex

workers to use public facilities without fear of discrimination, and other

marginalized groups such as street children. Training is needed in how to provide

advice for prevention in PTCT, such as management of mastitis and breast problems

[that may facilitate HIV transmission], support for exclusive breast-feeding or exclusive artificial feeding. Many of these activities we assume health workers must

know, but in fact they do not. Doctors are the least equipped to support infant feeding or to give advice on testing. In addition doctors and other health workers need

more intensive training in how to support relatives in home based care and symptomatic management of HIV related pain and illness. If ARVs become available this

will be a further area for training, not only in treatment and monitoring of treatment, but also in how to ensure equity in provision of treatment. There are training

courses usually associated with universities in the region that can cater for many

of these training needs but they are often inaccessible because of costs of travel, accommodation, course fees. Again, facilitating attendance and follow up at these

courses would be an important use of donor money but is often not provided because

of the administration involved in small grants.

98

In conclusion, the literature around what is effective in prevention, treatment and

care in HIV/AIDS is vast and could not be covered adequately in this paper. What

is crucial now is learning how to put what we know into practice, with feedback and

follow up built in to research and programme work. It is difficult to implement any

of these programmes beyond pilot projects when health staff are deskilled and in

poor morale, when health services are run down and unable to provide comprehensive care, with poor linkages with communities. To respond to the HIV epidemic in

appropriate and timely ways requires massive investment and support to public

health service provision, training and skills development in all public sectors on

HIV, and flexible, streamlined and coordinated donor responses to the most major

and catastrophic social disaster of our time in the southern Africa region.

Senator FRIST [presiding]. Thank you, Dr. Ray.

Dr. Okaalet.

STATEMENT OF PETER OKAALET, M.D., AFRICA DIRECTOR,

MEDICAL ASSISTANCE PROGRAM INTERNATIONAL,

NAIROBI, KENYA

Dr. OKAALET. Chairman Biden, in absentia, distinguished Senator Frist, fellow partners in the struggle against HIV and AIDS,

thank you for inviting me to bring before you today both a challenge and an opportunity.

My name is Peter Okaalet. I am a Ugandan-born physician who

leads MAP International’s HIV and AIDS work in Africa. The credentials I offer on this subject are three-fold. As an African physician, I have treated dying patients of HIV and AIDS. As an African

theologian, I have counseled them and comforted their grieving relatives. And as a family member, I have been, and still am, brother,

uncle, and cousin to those dying of HIV and AIDS.

I do not wish to discuss the program today, but instead to speak

of a unique resource to combat the disease. In every community,

from the smallest, most remote village to the largest urban centers,

there is an institution that is always present. It can muster tremendous human resources. It has infrastructure in place. It is

truly grassroots, and it can influence behavior, politics, and social

justice. In fact, in many instances, it has changed the course of

human events. From my Christian background, I will refer to this

simply as the church, but please hear the term and recognize that

for the purpose of this testimony, I will use that to encompass all

organized religion and all faith-based institutions.

To quote from a 1995 UNICEF report: ‘‘Religion plays a central,

integrating role in social and cultural life in most developing countries. There are many more religious leaders than health workers.

They are in closer and regular contact with all the groups in society and their voice is highly respected. In traditional communities,

religious leaders are often more influential than local government

officials or secular community leaders.’’

I offer you today the church as a powerful tool with which to address both HIV and AIDS prevention and care. In truth and humility, we in the church recognize that our tool has been badly flawed.

As the AIDS pandemic spread, it exposed fault lines that ran in the

heart of our theology, ethics, and actions. The church was too often

an obstacle in the fight. We looked the other way when customs

and traditions flew in the face of religious teachings, and we created unnecessary factions over the condom issue. We called people

living with HIV and AIDS sinners, and we too often ostracized

99

them rather than embraced. We as religious leaders were loathe to

discuss the issue of sex and death with our families, communities,

and never from the pulpit. In many cases, we increased rather than

ameliorated the suffering and separation of the ill and the dying.

But I am here to tell you that in Africa, I am hearing recognition

that we have been part of the problem. I am also seeing that we

are an integral part of the solution. Religious-based institutions,

when properly supported and coordinated, can be some of the most

strategic vehicles through which to slow the spread of HIV and

AIDS.

This past November, for example, at the Global Consultation of

the Ecumenical Response Against HIV and AIDS was held in

Nairobi. Also in November of last year, 580 representatives from 31

nations, representing 70 million members of the Association of the

Evangelicals in Africa met in Burkina Faso and together declared

that the church must address poverty and HIV and AIDS. The participants left energized and committed for the raging battle. The

call to action does not demand uniformity in response, but it does

demand a resolve to speak openly and honestly about the disease.

The church also recognizes that the AIDS pandemic has systemic

issues that are rightly the domains of the church: namely, violence,

gender inequality, poverty, human rights, and social justice. The

future holds great promise, building upon what the church has already done to address HIV and AIDS. I would like to cite a few

success stories.

Uganda, my home country, is often cited for the most dramatic

reduction in HIV infection rates. It is not mere coincidence that the

period when the rates plummeted, especially between 1991 and

1998, was a period of marked involvement by the Anglican, Catholic, and Muslim religious organisations. Their messages of fidelity

and abstinence echoed the approach strongly favored by President

Museveni. Senator Frist, you have already refereed to his wife coming to address a conference that will be taking next week.

Several studies have documented behavior change, including reduction in sexual partners, delay of sexual debut, and abstinence.

A UNAIDS best practices study of the Islamic Medical Association

in Uganda shows that AIDS prevention activities carried out

through religious leaders did have a significant impact in reducing

the spread of AIDS. As behavior continued to change and HIV infection rates declined, several other religious groups became involved under the coordination of the ministry of health. Dr. Edward

Green, a consultant of the Synergy Project and Harvard School of

Public Health, studied the Ugandan model and estimated that in

1995 over 2,700 trainers and peer educators, as well as about 5,600

community volunteers in the Muslim IMAU project alone, had

reached nearly 200,000 households and had counseled or sensitized

over 1 million sexually active people.

In Zambia, the Salvation Army has been on the forefront of HIV

and AIDS prevention and control strategies. They have supported

institutional care of people living with HIV and AIDS in

Chikankata Hospital, for example. Their program reflects the continuum of care model that is essential in the face of this pandemic.

The organization that I represent, a Georgia-based PVO, Medical

Assistance Program International, has its own success stories in

100

Kenya. With funds received from USAID through Family Health

International, MAP launched its project which was dubbed Integrated Action Against AIDS with Kenyan Churches in 1994. MAP

has worked since, across the denominational spectrum, from Pentecostal to Roman Catholic congregations, conducting training in HIV

and AIDS prevention and compassionate care ministries. The

project incorporated baseline research, material development and

dissemination, networking, and policy formation with top-level

leaders and grassroots practitioners. It developed a peer education

program, youth-to-youth, training adolescents in various parts of

Kenya, especially in the schools and churches.

MAP, in partnership with a select number of theological institutions in Kenya, began to develop a curriculum on HIV and AIDS

targeting seminaries and bible schools in sub-Saharan Africa. The

rationale for this project was the simple fact that clergy and church

leaders were sadly unprepared to deal with the HIV and AIDS impact, especially in the churches and in the communities. As most

of us have found out working with religious leaders, the official

duty that a young African clergy fresh from seminary or bible

school would be called upon to perform would most likely be a

graveside service for someone who had died of HIV and AIDS, not

a biblical exegesis from the pulpit on a Sunday morning. Seminarians usually graduate with a knowledge of Hebrew, but have little

knowledge on the subject of the prevention of sexually transmitted

diseases, including HIV and AIDS.

In 1996, MAP developed a series of curriculum modules that address HIV and AIDS, targeting especially again the theological

schools. Some of the modules included such modules as facts about

transmission, advice on mobilizing church resources, information

about home-based care, and other AIDS-related issues imperative

for a church leader to grapple with when they graduate from theological school.

In June of 2000, the ministry of health in Kenya opened another

workshop that brought together theologians from east and southern Africa to discuss the subject of HIV and AIDS and try to create

a curriculum targeting theological schools again in that region. We

are pleased to report that through a grant from the Episcopal Relief and Development Fund in New York this fall, four Anglican

seminaries in Kenya, Uganda, Zambia, and South Africa have accepted the challenge and will integrate HIV and AIDS courses in

their curriculum.

MAP has worked closely with people of other faiths, especially

the Muslims in Kenya. Last October, for example, at the request

of the National AIDS Control Council, MAP organized an inter-religious conference on the role of faith-based organizations in combating HIV and AIDS that included Christians, Muslims, Sikhs,

and Hindus.

The examples I cite above have a number of common threads: a

proactive program reaching across denominations, strong coordination and effective follow-up, and a partnership among government,

secular, and religious sectors. Partnership is essential to any effective broad-based program such as the one that I am talking about.

The Uganda model used World Bank funding, government backing, and faith-based organizations’ networks and training ability.

101

MAP’s experience in Kenya would never have been possible without the initial funding from USAID’s AIDS Control and Prevention

Project, AIDSCAP. MAP was supported by the World Health Organization to carry out also some other home-based care in western

Kenya. UNAIDS has funded most of the work that we have done,

and I am sorry that Dr. Peter Piot is not here to hear some of the

vote of thanks that I wanted to give to him at this time.

AIDS is not just a medical problem and not just a public health

issue. It is also a behavioral issue. MAP International promotes the

ABC approach: abstinence until marriage, being faithful in marriage, and condom usage where warranted.

While MAP does not make a judgment for other groups about the

use of condoms, it does advocate for a participatory approach in

discussion of the issue. I wish to stress that behavior change is not

synonymous with condom usage. Like a pebble tossed into a lake,

behavior is but a ripple effect of deeper issues, values and choices.

This would suggest that one cannot speak of behavior change necessary to combat HIV and AIDS without addressing the core issues

of poverty, injustice, and the exploitation of women, what my other

colleagues have already referred to, basic human rights, enough

food to eat, enough clean water to drink, a roof over one’s head,

and a way to make a living.

A mother of four in my country who can make the equivalent of $3 for having unprotected sex with a client or $1 if she demands

he wear a condom can hear the message of safe sex all day, but

it will not drown out the hungry cries of her children.

A 10-year-old in South Africa who is forced to have sex with an

HIV-infected person, especially a man much older than her, who

believes that sex with a virgin will cure him, is an inappropriate

target for the ‘‘wait until you are married’’ kind of talk.

Neither faith-based organizations nor governments nor world assemblies can separate the AIDS pandemic from the larger social

and political issues. One of the most effective strategies in the

Uganda AIDS success story was the use of debt relief to expand the

AIDS control effort. Recognition of the root causes, resource pooling, and coordination are key, with each player bringing to the

table the very finest resource in their arsenal.

Last May, Christian Connections for International Health

brought together about 166 participants representing 25 countries

to an AIDS, TB, and malaria conference which was held at the

First Presbyterian Church of Arlington, Virginia. The venue was a

house of worship, but the participants represented WHO, UNAIDS,

USAID, CDC, pharmaceutical representatives, academicians, congressional staff, and secular NGO’s, in addition to the faith-based

organizations represented.

As already alluded to, next week another assembly convened by

the Samaritan’s Purse, whose team is here present under the leadership of Ken Isaacs, will draw representatives, over 900 of them

at least, from the same diverse sectors, all focused on AIDS and the

broader issues of poverty and human rights, all committed to the

fact that the time has come to present a united front in face of this

pandemic.

I would now like to pose three key questions and suggest a few

answers as I close.

102

Senator FRIST. Dr. Okaalet, just because the Secretary-General

is going to start here in a few minutes, summarize in a couple of

minutes. Your testimony will be read by everybody. The questions

are great and the answers are great because I had an opportunity

to look at those earlier. But summarize those and we will go

through one round of questions. Then we will have to close.

Dr. OKAALET. Thank you.

The first question, what do we, the faith community, offer the

world in the fact of this pandemic? A track record of 2,000 years

of history of care and support to those who are in situations like

those HIV and AIDS people find themselves in. Responsiveness and

commitment, integrity, access, moral authority, advocacy, and a holistic approach.

Second, how do we, the faith community, construct a new plan

of action to address HIV and AIDS? We will condemn discrimination and stigmatization. We will seek out partners. We will advocate broadening the discussion on HIV and AIDS to include other

issues that are no-touch subjects like sex and sexuality, even

preaching about them from the pulpit. We will educate. We will

promote effective means of prevention. We will commit resources to

care and counseling. We will challenge culture and traditions.

Lastly, what do we, the people of faith, ask of you in the committee? Number one, that you continue to create space in which to

engage us, be it through formal offices for faith-based initiatives,

conferences, or informal discussions. Second, that you help leverage

the tremendous financial resources of the United States and the

western world to engage the pandemic even more aggressively. And

lastly, that you continue to shift resources like those through the

USAID CORE initiative to grassroots faith-based organizations and

institutions in the front lines of the battle who have proven that

they can indeed be committed allies to defeating this pandemic.

Thank you, Mr. Chairman.

[The prepared statement of Dr. Okaalet follows:]

PREPARED STATEMENT OF PETER OKAALET, MD, M.TH, M.DIV., AFRICAN DIRECTOR, MAP INTERNATIONAL

THE ROLE OF FAITH BASED ORGANISATIONS IN THE FIGHT AGAINST HIV AND AIDS

Chairman Biden, distinguished Senators, fellow partners in the struggle against

HIV and AIDS, thank you for inviting me to bring before you today both a challenge

and an opportunity.

My name is Peter Okaalet. I am a Ugandan-born physician who leads MAP International’s HIV and AIDS work in Africa. The credentials I offer on this subject are

three-fold: as an African physician, I have treated dying AIDS patients; as an African theologian, I have counseled them and comforted their grieving relatives; as an

African family member, I have been—and still am—brother, uncle, and cousin to

those dying of AIDS.

I do not wish to discuss the problem today, but instead to speak of a unique resource to combat the disease. In every community—from the smallest, most remote

village, to the largest urban centers, there is an institution that is always present.

It can muster tremendous human resources; it has an infrastructure in place; it is

truly ‘‘grass-roots;’’ and it can influence behaviour, politics, and social justice. In

fact, in many instances it has changed the course of human events. From my Christian background, I will refer to it as the Church. But please hear that term and

recognize, that for the purpose of this testimony, I will use that to encompass all

organized religion and all faith-based institutions.

To quote a 1995 UNICEF report:

‘‘Religion plays a central, integrating role in social and cultural life in

most developing countries... there are many more religious leaders than

103

health workers. They are in closer and regular contact with all age groups

in society and their voice is highly respected. In traditional communities,

religious leaders are often more influential than local government officials

or secular community leaders.’’ (Religious Leaders as Health Communicators. New York, NY:UNICEF, 1995)

I offer you today the Church as a powerful tool with which to address both HIV

and AIDS prevention and care. In truth and humility, we in the Church recognize

that our tool has been badly flawed. As the AIDS pandemic spread, it exposed fault

lines that ran to the heart of our theology, ethics, and actions. The Church was too

often an obstacle in the fight: we looked the other way when customs and traditions

flew in the face of religious teachings; we created unnecessary factions over the

condom issue; we called people living with AIDS sinners; and we too often ostracized

rather than embraced. We as religious leaders were loathe to discuss issues of sex

and death within our families, communities, and never from the pulpit. In many

cases, we increased, rather than ameliorated, the suffering and separation of the ill

and the dying.

But I am here to tell you that, in Africa, I am hearing recognition that we have

been part of the problem. I am also seeing that we are an integral part of the solution. Religious-based initiatives, when properly supported and coordinated, can be

some of the most strategic vehicles through which to slow the spread of HIV and

AIDS. This past November, at a Global Consultation on the Ecumenical Response

to the Challenge of HIV and AIDS in Africa held in Nairobi, this was confirmed.

Also in November, 580 representatives from 31 African nations representing 70 million members of the Association of Evangelicals in Africa met in Burkina Faso and

together declared that the church must address poverty and HIV and AIDS. The

participants left energized and committed for the raging battle. The call to action

does not demand uniformity of response—but it does demand a resolve to speak

openly and honestly about the disease, about sexuality and about behaviour, and to

act practically, compassionately, and nonjudgmentally in response to it. To quote

one of the plans of action from the conference: ‘‘It is time to speak the truth. It is

time to act only out of love. It is time to overcome fatigue and denial And it is time

to live in hope.’’

The Church also recognizes that the AIDS pandemic has exposed systemic issues

that are, rightly, the domains of the Church: namely, violence, gender inequality,

poverty, human rights, and social justice. The future holds great promise, building

upon what the Church has already done in addressing AIDS. I would like to cite

a few success stories:

Uganda, my home country, is often cited for the most dramatic reduction in HIV

infection rates. It is not mere coincidence that the period when the rates plummeted, 1991-1998, was a period of marked involvement by Anglican, Catholic, and

Muslim religious organisations. Their messages of fidelity and abstinence echoed the

approach strongly favored by President Museveni. Several studies have documented

behaviour change—including reduction of sexual partners, delay of sexual debut,

and abstinence. A UNAIDS ‘‘Best Practices’ study of the Islamic Medical Association

of Uganda (IMAU) shows that AIDS prevention activities carried out through religious leaders had significant direct impact. As behaviour continued to change and

HIV infection rates declined, several other religious groups became involved under

the coordination of the Ministry of Health AIDS prevention activities, funded by the

World Bank. Dr. Edward C. Green, consultant to the Synergy Project and Harvard

School of Public Health, studied the Uganda model and estimated that in 1995 over

2,745 trainers and peer educators as well as 5,629 community volunteers in the

Muslim IMAU project alone had reached nearly 200,000 households and had counseled or sensitized over 1 million sexually active people. The Anglican project had

reached nearly 3/4 million Ugandans.

In Zambia, the Salvation Army has been on the forefront of HIV and AIDS prevention and control strategies. They have supported institutional care of people living with HIV and AIDS in Chikankata Hospital. Their program reflects the continuum of a care model that is essential in the face of this pandemic.

The organisation I represent, a Georgia-based PVO, MAP (Medical Assistance

Programs) International, has its own success story in Kenya. With funding from

USAID, through Family Health International, MAP launched its project, ‘‘Integrated

Action Against AIDS with Kenyan Churches’’ in 1994. MAP has worked since,

across the denominational spectrum, from Pentecostal to Roman Catholic congregations, conducting training in HIV and AIDS prevention and compassionate care ministries. The project incorporated baseline research, material development and dissemination, networking, and policy formation with top-level leaders and grass roots

104

practitioners. It developed a peer education program, youth-to-youth, training adolescents to counsel their peers in Kenyan churches and schools.

MAP, in partnership with a select number of theological institutions in Kenya,

began to develop a curriculum on HIV and AIDS targeting seminaries and bible

schools in sub-Saharan Africa. The rationale for this project was the simple fact that

clergy and church leaders were sadly unprepared to deal with AIDS and its impact

on their churches and communities. The first official duty that a young African clergyman, fresh from seminary or bible school, would be called upon to perform would

most likely be a graveside service for someone who had died of AIDS, not a biblical

exegesis from the pulpit! Seminarians usually graduate with knowledge of Hebrew,

but have limited knowledge on the subject of the prevention of sexually transmitted

diseases.

In 1996 MAP developed a series of curriculum modules addressing the biblical

foundations for an HIV and AIDS church initiative, facts about transmission, advice

on mobilizing church resources, information about home-based care, and other

AIDS-related issues imperative for a church leader to grapple with. In June 2000,

MAP, in partnership with the World Council of Churches and UNAIDS, hosted a

forum that attracted academic deans, principals, and representatives from 20 theological institutions from 14 countries in East and Southern Africa. The outcome was

a draft curriculum with a challenge to take it, adapt it to the particular denomination or country, and require its use in the seminaries and bible schools.

We are pleased to report that, through a grant from the Episcopal Relief and Development Fund in New York this fall, four Anglican seminaries in Kenya, Uganda,

Zambia and South Africa have accepted the challenge and will be integrating the

HIV and AIDS courses into their curriculum.

MAP works closely with the Ministry of Health and has held a seat on the board

of the Kenya AIDS NGO Consortium (KANCO) since its inception. This consortium

includes government, faith-based organisations, international organisations, and

secular NGOs.

Working with the Muslim community in Kenya, MAP has made great strides in

interfaith alliances. HIV and AIDS prevention radio spots, created by MAP for the

Kenya Broadcasting Corporation, patterned themselves after Islamic calls to prayer.

Discussions have been held with the Imam of the largest mosque in Nairobi. Last

October, at the request of the Kenyan National AIDS Control Council, MAP organized an inter-religious conference on the role of faith-based organisations in combating HIV and AIDS, that included Christians, Muslims, Sikhs, and Hindus.

The examples I cite above have a number of common threads: a proactive program

reaching across denominations; strong coordination, and effective follow-up; and a

partnership among government, secular, and religious sectors. Partnership is essential to any effective, broad program.

The Uganda model used World Bank funding, government backing, and the faithbased organisations’ networks and training ability. MAP’s experience in Kenya

would never have been possible without the initial funding from USAID’s AIDS

Control and Prevention (AIDSCAP) Project. MAP was supported by the World

Health Organization (WHO) to carry out a home care study. UNAIDS funds much

of our conference and networking work. The faith-based initiative offices of USAID

and the World Bank offer consulting and networking opportunities. Clearly, bilateral and multilateral agencies are recognizing and responding to the potential offered by partnering with faith-based organisations to combat HIV and AIDS. Archbishop Desmond Tutu, among others, has forcefully called for a concerted effort by

all to rise up to the challenge posed by HIV and AIDS. He challenged global leaders

to look beyond their differences and to join hands in solidarity against this pandemic.

AIDS is not just a medical problem . . . and not just a public health issue—it is

also a behavioural issue. MAP International promotes the ABC approach: Abstinence until marriage, Being faithful in marriage, and Condom usage when warranted. To complement this prevention strategy, MAP also emphasizes care and

support of people infected and affected by HIV and AIDS, thus addressing the entire

continuum of care—prevention, care, and support.

While MAP does not make a judgment for other groups about use of condoms, it

does advocate for a participatory approach in discussion of the issue. I wish to stress

that ‘‘behaviour change’’ is not synonymous with condom usage. Like a pebble tossed

into a lake, behaviour is but the ripple effect of deeper issues, values and choices.

This would suggest that one cannot speak of the behaviour change necessary to

combat HIV and AIDS without addressing the core issues of poverty, injustice, exploitation of women, and basic human rights to enough food to eat, enough clean

water to drink, a roof over one’s head, and a way to make a living.

105

A mother of four in my country who can make the equivalent of $3 for having

unprotected sex with a client—or $1 if she demands he wear a condom—can hear

the message of safe sex all day, but it will not drown out the hungry cries of her

children. A ten year old in South Africa who is forced to have sex with an HIV-infected man who believes that sex with a virgin will cure him, is an inappropriate

target for the ‘‘wait until you are married’’ talk.

Neither faith-based organisations, nor governments, nor world assemblies can separate the AIDS pandemic from these larger social and political issues. One of the

most effective strategies in the Uganda AIDS success story was the use of debt relief

to expand AIDS control efforts. Recognition of the root causes, resource pooling, and

coordination are key, with each player bringing to the table the very finest resources

in its arsenal. Last May, Christian Connections for International Health brought together 166 participants from 25 countries to an AIDS, Malaria, TB conference held

at the First Presbyterian Church of Arlington, Virginia. The venue was a house of

worship, but the participants represented WHO, UNAIDS, USAID, CDC, pharmaceutical representatives, academicians, congressional staff, and secular NGOs, in addition to the faith-based organisations represented. Next week, another assembly

convened by Samaritan’s Purse will draw representatives from the same diverse sectors—all focused on AIDS and the broader issues of poverty and human rights. All

committed to the fact that the time has come to present a united front in the face

of this pandemic.

I would now like to pose three key questions, and suggest a few answers:

What do we, the faith community, offer the world in the face of this pandemic?

(Quoted in part from a Christian Connections in International Health document):

• A track record—A 2,000 year history of quality care for the sick and the dying.

In many African countries, religious organisations provide 30-50% of the hospital beds in the country.

• Responsiveness and long-term commitment—Faith based organisations respond

quickly to difficult situations, accepting challenges other institutions ignore or

quickly abandon when they linger or become unfashionable.

• Integrity—Individuals in America and around the world give more of their philanthropic dollars to religious institutions than to any other group. On the

whole, religious groups have a record of fiscal responsibility and a divine mandate to be good stewards of the resources allotted them.1 • Access to a wide audience and community involvement.

• Moral authority—religious leaders can influence communities, societies, nations,

and the course of human events.

• Advocacy—Religious institutions champion the poor, the marginalized, the

disenfranchised.

• A holistic approach—melding the spiritual, physical, mental and social aspects

of health and balance.

How do we, the faith community, construct a new plan of action to address HIV

and AIDS? (Quoted in part from the Plan of Action: The Ecumenical Response to

HIV and AIDS in Africa, Kenya, November 2001)

• We will condemn discrimination and stigmatisation and will embrace people living with AIDS.

• We will seek out partners in government, business, and the international community, pooling resources to form the most efficient, effective response to the

pandemic.

• We will advocate broadening the discussion of HIV and AIDS to include issues

of gender, violence, political inequity, and poverty.

• We will educate ourselves and those under our care—with special emphasis on

our new generation of leadership and our youth.

• We will promote effective means of prevention. In doing so, we will support the

churches’ historic commitment to faithfulness and abstinence, while allowing

latitude for means beyond these that have proven effective in reducing risky behaviour.

• We will commit resources to care and counseling in addition to prevention and

education.

• We will challenge culture and traditions, identifying those practices that are

antithetical to our teachings and harmful to health, and proposing alternative

rites and rituals in place of these harmful practices.

What do we, the faith community, ask of you?

• That you continue to create spaces in which to engage us—be it through formal

offices for faith-based initiatives, conferences, or informal discussion.

106

• That you help leverage the tremendous financial resources of the United States

and the Western World to engage the pandemic even more aggressively.

• That you continue to shift resources, like those through the USAID CORE initiative, to grass-roots faith-based organisations and institutions in the front

lines of the battle and have proven their effectiveness, often with few resources.

In closing, my distinguished colleague, Dr. Peter Piot of UNAIDS, has said that

although AIDS has been an issue for twenty years now, ‘‘it is a tale that is still

in its opening chapters.’’ While it is true that because of the long lead-time between

infection and manifestation of the symptoms, what we are seeing, especially in Asia

and Latin America, may only be the first few chapters of this macabre tale. It is

also true, however, that faith-based organisations that heretofore have been introduced in a supporting role in these first few chapters, in fact will become integral

to the story and may well determine the story’s outcome.

Senator FRIST. Thank you very much.

Dr. Okaalet, where do you live? Are you in Uganda or Kenya?

Dr. OKAALET. I live in Nairobi.

Senator FRIST. And where did you go to medical school?

Dr. OKAALET. I went to Maketeda Medical School in Uganda.

Senator FRIST. And you are licensed to practice in Uganda then

still?

Dr. OKAALET. Both in Uganda and in Kenya.

Senator FRIST. Well, you and I—and I say this quite proudly—

are probably the only two people in the room who are licensed to

practice medicine in Uganda. As you may know, I had the opportunity to operate alongside the Vice President of Uganda who is a

surgeon in the medical center there, which has a tremendous tradition in terms of producing I guess the first three physicians in subSaharan Africa long ago. It was a real pleasure for me to operate

alongside her.

But in my office, I have a 3-month temporary license to practice

in Uganda. So, I have got another 2 and a half months.

I wish we had more time because each of these three dimensions

are fantastic and they really integrate one with another. Mr.

Lyman mentioned the role of the church and the role of faith-based

organizations. Clearly as we tie in with the NGO’s, the faith-based

component, given what the predominance in Africa is, for the reasons that you closed with, Dr. Okaalet, in terms of the foundation,

the long-term care, the long-term involvement plays a huge role,

and I am impressed by it every time I go to Africa.

Several questions real quick and then we will wrap up for the

Secretary-General.

Dr. Ray, we have talked a lot about the Global Fund, and I think

over the course of the last 4 hours, it has been an appropriate perspective where people look to it, know it is not the answer. It is

important that we continue to invest, I would argue, very heavily

in that fund. But whatever we do here in Washington, DC in making decisions, it is important that that money gets down to your

groups, to your constituents.

In addition to being in Uganda, I was in Tanzania and met there

with Sister Denise, again with the Catholic diocese there. She told

me exactly the same thing. We see this money coming down. It gets

all the way down to the country level. It gets down to the local

level. It gets down to even the community level, and it is a chunk

of money. But it rarely gets down to right where you need it. We

107

just got to continue to address that by hearing from people such

as you in a direct way.

My question is for the Global Fund. And you are stressing you

need managers and administrators as well as physicians, nurses,

people on the ground. When we have this new Global Fund that

is being set up, will your NGO’s have the expertise to put together

an application that does have enough finances, accountability

there, or not? You made the case of the need of those sorts of people, but if you do not have those people now and you have got to

fill out an application, that I have not seen, but I assume asks for

a lot of data and all, does that put you at a disadvantage?

Dr. RAY. The issue with the Global Health Fund is interesting

because we had understood that there had to be one country response, which means that relies very much on having a good working partnership usually between government and big NGO’s, so

that they put together some kind of proposal and submit it.

Then my experience with how people get grants is it is based

very much on reputation. So, for instance, in my organization I can

certainly pull together a funding proposal, and I have a good

enough relationship with donors that if I am convincing, they will

consider it. If an organization says we want to develop a leaflet in

local languages on the five symptoms of TB that every HIV-positive

person needs to know and we want to a print run of 10,000, that

activity would probably have major impact in those 10,000 people,

but they will not get funding for it. So, it depends on whether my

organization can then say, okay, we will administer the grant for

you, which means that then I have to hire three more people just

to administer and to do the reporting for all the little organizations

that need that kind of support.

Some of those organizations will be corrupt. Some of them will

not be able to do what they set out to do just because they are not

skilled or trained. I am not in a position where I can micromanage

them, and that is where the whole thing falls apart.

I think what we are asking for is just some latitude, some flexibility so that donors actually have a part of that money which is

available for small grants, and where they are not asking for great

reporting requirements. The kind of stuff that we get from the donors is like that.

Senator FRIST. You understand that a lot of the NGO’s throw

money away. It is wasted. And that is the real challenge. Obviously, having people such as you who can interact with a lot, but

by having too much flexibility and not enough reporting and not

enough accounting, it is hard for me to make the case with the

American people because, as you know, some of the NGO’s do not

do a good job or you give it to the NGO and it still does not make

it down to the level. That is the real challenge that we have as we

go forward.

Dr. RAY. But I think the World Bank itself has begun to face

that. The last time they talked with us, they were actually saying,

okay, the majority of our funding has to have that kind of funding

requirement where people fill in these forms and have audited reports and that kind of thing. But we can now make small amounts.

It is almost like saying it is worth the risk to have a small amount

108

of money that could be thrown away, but maybe if a quarter of it

works, that it is worth it.

In a sense organizations like mine can support the product. What

is difficult for us to support is the proposal writing, the report writing, all the admin that goes in organizing things. So, in a sense if

USAID or DANIDA or the British DFID said to us, can you help

develop this leaflet, we could say, yes, of course, we can help them

develop the leaflet. But what we cannot do is do their audited accounts for them.

Senator FRIST. Very well said.

Mr. Lyman, I feel like I should come back to you, but I am going

to be seeing you so much over the next few months and I am not

going to see the other two. So, selfishly let me again turn back to

Okaalet.

Where have the churches been? I think your written presentation

is really perfect. As a matter of fact, I turned to my staff and said

this really paints the picture where you have been. The potential

is there. United States churches have locked up too, and they have

locked up, have not addressed it, and we have clearly got to mobilize here. We have the stigmatization in this country. We have the

same problems that you have had to face in Africa.

You mentioned the Samaritan’s Purse conference next week, the

conferences in Africa. Do you think you will be able to mobilize the

churches?

I know in Uganda I guess the person who runs the overall AIDS

program is——

Dr. OKAALET. A bishop.

Senator FRIST [continuing]. A Catholic bishop, which is just

again gratifying to me to see because a lot of the work I have done

has been through mission fields and all.

Do you think we could bring them to the table? Not bring them.

Obviously, they are coming to the table, but help paint the picture

for me and for my colleagues. They have not been there in the past

nor have they been in the United States. Is the opportunity there

for us to realize now?

Dr. OKAALET. I believe, Senator Frist, the opportunity is here

and the opportunity is with us now.

When you say where has the church been, I think that there are

many reasons to explain why the church has not been actively involved. One of them is stigma that several other speakers already

referred to.

The other one is HIV and AIDS causes death, and in Africa it

is not a subject that many people want to talk about freely.

Ninety percent of the people who contract HIV/AIDS is through

heterosexual contact, one infected person and the other. Sex and

sexuality is no-touch subject. In some of the meetings that we have

conducted in western Kenya, a pastor has come forward to say, doctor, if you are to help us survive this disease, then you need to be

coming more from Nairobi to Kisumu because I cannot preach

about it. I cannot talk about sex and remain accepted in my community. Because HIV and AIDS touches on sex and sexuality, Africans have found it very difficult to talk about it openly. Because

it causes death, again it is a bit difficult.

109

But there is a Chinese proverb that says a journey of a thousand

miles begins with one step. I think several steps have already been

taken. Our own experience working with the churches in Kenya are

that the church has gone through four phases. The first phase,

those who did not work with us directly, those who have not helped

to train their pastors and so on, always were resistant. HIV and

AIDS is caused through sin, so let sinners get out of the church.

Isolate them. That is what I characterize as judgmental attitude

holding your fist against the face of another person.

Second, there has been a lame kind of response. I am talking as

a medical doctor. If somebody has a lame hand, it becomes difficult

to greet another person the African way, the way we greet. Because

they will not respond. They are not trained. There is no capacity

as some of my fellow speakers have already said. The response has

been very lame.

Thirdly, there is what I characterize as a gloved response. People

want to respond but they want to be protected. For example, a pastor would go into a ward and rather than touch and lay hands on

a patient who is sick, he will stand at the door and say, God bless

you, and then walk away before he touches them. But now we are

challenging them if Jesus were alive today, would he touch an HIV

and AIDS person like he touched leprosy people? Yes, he would.

But we are moving them from the judgmental attitude, from the

lame response, from a protected, over-cautious response to recognize that we need to embrace those who are sick with HIV and

AIDS. If the church is absent today, it will be irrelevant tomorrow

when so many of the Africans will be dying and everybody will be

asking, as you are correctly asking, Senator, where were you when

we needed you. So, the time to respond for the church is now.

And I believe as MAP International, working together with many

other partners, we have trained several people in Kenya. I was in

Namibia with another colleague from MAP International training

all the Anglican pastors and two of their bishops in Namibia about

a month ago.

Senator FRIST. I think we have a lot to learn from Africa in so

many ways, but I think this is a good example. I think what is

bringing people to the table a lot is that the continent is being destroyed and so people recognize they have to face it. When you look

in the Caribbean, which has the second fastest growing, or you look

at Russia, which has the fastest growing incidence of AIDS, or

India where we have more people with AIDS than any other country in the world, I think all, including the United States, can learn

from the faith-based organizations in Africa who are coming to the

table facing it head on.

I am going to have to close because I have got 3 minutes to get

over to our meeting with the Secretary-General.

For the record, Mr. Lyman, if you could summarize the survey

briefly in, say, two or three pages in terms of some of the data that

I would like to make available to my colleagues and the record as

well in terms of the current attitudes in the United States.

Ambassador LYMAN. We will do that.

Senator FRIST. Let me thank all of you. Again, we are going to

be spending the next hour with the Secretary-General. Tomorrow

we have a hearing that will continue the discussions and the procVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00113 Fmt 6633 Sfmt 6602 77846.001 SFRELA2 PsN: SFRELA2
110

ess that we have begun today. The three of you have been very,

very patient, and for everyone who has participated today, I want

to say thank you.

Dr. Ray, in 30 seconds or less.

Dr. RAY. Just a promotion. I did not manage to bring our materials because they were lost at the airport somewhere. But they

will be available through Heather. If anybody here wants to see

some of the materials we produce, particularly on boys and men

and HIV, they can get copies from her.

Senator FRIST. And we will make sure that gets distributed to

the group.

With that, we stand adjourned.

[Whereupon, at 3:15 p.m., the committee was adjourned.]

ADDITIONAL STATEMENT SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF SENATOR GORDON H. SMITH

I want to thank Chairman Biden for the opportunity to talk about the plight

AIDS has caused on not just the world economy but on the infrastructure of every

country and every family it touches.

And I want to thank our panels—especially Secretary Thompson, for taking the

time to talk about the spread of AIDS worldwide.

We come here to talk about the spread of AIDS worldwide—but I want to take

a moment and note since we do have the Secretary of Health and Human Services

present, that this is a disease that touches every state in the Union—including my

home state of Oregon.

Last year marked the 20th anniversary of AIDS in the United States and sadly,

the death of a constituent of mine.

I am speaking of the 1981 CDC report that noted the appearance of a rare type

of pneumonia that had struck five gay men. One of those five men was an Oregonian—a man named ‘‘Chuck’’ whose place in history is a CDC report that this country took too long to respond to—Chuck has been dead for almost 20 years now.

But I am pleased with Secretary Thompson’s interest in these issues—we have

spoken in the past about Oregon’s AIDS crisis—the numbers—we have had 5,000

cases of AIDS in Oregon alone since 1985. And I have asked him to expand Medicaid access for those with HIV/AIDS.

Just a few years ago this very committee took the lead in finding necessary funds

for fighting AIDS in sub-Saharan Africa and found the bipartisan spirit to pass authorizing legislation to fight AIDS world wide.

But now the world is facing a global health problem of disastrous proportions in

the global HIV/AIDS pandemic.

In the past few years, this issue has received much needed attention from the

international community and the U.S. government.

But, unfortunately, our efforts and the efforts of other governments, the private

sector, and foundations have not been enough and the pandemic continues to wreak

havoc on the lives of millions of people around the world.

We now face AIDS not just in Africa—but the onslaught in Central and Eastern

Europe, in Russia, in China and in South East Asia . . . while we may hear many

statistics today . . . it is important to remember that this disease is threatening the

whole world—it knows no boundaries and no politics.

I look forward to our testimony from the Administration, academia and the private sector.

RESPONSE TO AN ADDITIONAL QUESTION SUBMITTED FOR THE RECORD BY SENATOR

HELMS TO DR. PETER PIOT

Question. According to a recent GAO report (December 2001) the United Nations

does not know how many peacekeepers have HIV/AIDS because it opposes mandatory HIV testing before, during or after deployment to a peacekeeping mission. With

all that we now know, with all the evidence we have that peacekeepers—like other

military personnel—are likely to engage in behaviours such as unsafe sexual pracVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00114 Fmt 6633 Sfmt 6621 77846.001 SFRELA2 PsN: SFRELA2
111

tices that increase the risk of contracting and spreading HIV, what is the rationale

for continuing this policy of not testing peacekeepers?

Answer. UNAIDS commends the GAO report on HIV/AIDS and peacekeeping (December 2001) for its comprehensive assessment of this important area, which has

also been given high priority by UNAIDS during the last year.

In view of the number and complexity of issues relating to HIV testing in UN

peacekeeping operations, and in response to concerns expressed by members of the

UN Security Council, the UNAIDS Secretariat, in close consultation with the UN

Department of Peacekeeping Operations (UNDPKO), initiated a comprehensive review of United Nations policy in this area. An Expert Panel on HIV Testing in UN

Peacekeeping Operations was established to assist in this effort. The panel was

chaired by a Justice of the High Court of Australia and included representation

from the USA Centers for Disease Control and Prevention, several military officials

from peacekeeper contributor nations, and other military, medical, social science

and legal experts in this area.

After careful review of the extensive empirical and qualitative data provided in

background documentation commissioned for the meeting and in other relevant

sources and international standards, the members of the panel unanimously recommended voluntary HIV counseling and testing as the most effective means of preventing the transmission of HIV, including among peacekeepers, host populations,

and spouses and partners of peacekeepers. No member of the panel endorsed mandatory HIV testing by or for the United Nations as a means to prevent the transmission of HIV to or by peacekeepers. The panel considered voluntary counseling

and testing to be an essential part of the response to HIV/AIDS among peacekeepers

and stressed that voluntary counseling and testing should be provided to peacekeeping personnel within a comprehensive package of integrated HIV prevention

and care programs.

In detailed substantiation of its recommendations, the expert panel also noted

that voluntary counseling and testing has been shown to be more effective than

mandatory HIV testing in promoting safe sexual behaviour and reducing other risks

involved in transmitting HIV or becoming infected. Further, the panel concluded

that mandatory HIV testing has not been shown to have demonstrable individual

or public health benefits and may result in significant negative outcomes. In sum,

while it concluded that mandatory HIV testing was neither necessary nor advisable

in the context of UN peacekeeping operations, the panel empahsized that voluntary

counseling and testing for HIV must be made available as an essential component

of HIV prevention in the context of peacekeeping and that peacekeepers should be

encouraged to avail themselves of these services.

During the past year, UNAIDS and the UN Department of Peacekeeping Operations (UNDPKO) have collaborated closely, and the United Nations has undertaken

a number of important measures and initiatives to address HIV/AIDS in peacekeeping operations. As requested by the UN Security Council, UNAIDS in collaboration with UNDPKO has produced a redesigned awareness and prevention strategy

for peacekeepers. Important initiatives also include the recruitment of HIV/AIDS officers attached to individual peacekeeping operations, and organization of workshops

with relevant medical and training staff of DPKO on putting in place measures to

prevent transmission of HIV/AIDS. At country level, UNAIDS and UNDPKO have

focused their collaborative efforts on the five main UN peacekeeping missions currently in operation, specifically those for Ethiopia and Eritrea (UNMEE); Sierra

Leone (UNAMSIL); the Democratic Republic of Congo (MONUC); Kosovo (UNMIK),

and East Timor (UNTAET).

(113)

RESPONDING TO AFRICA’S HIV/AIDS CRISIS:

THE ROLES OF PREVENTION AND TREATMENT

THURSDAY, FEBRUARY 14, 2002

U.S. SENATE,

COMMITTEE ON FOREIGN RELATIONS,

Washington, DC.

The committee met, pursuant to notice, at 2:30 p.m. in room SD–

419, Dirksen Senate Office Building, Hon. Russell D. Feingold

(chairman, Subcommittee on African Affairs), presiding.

Present: Senators Feingold and Frist.

Senator FEINGOLD. I call the hearing to order. I want to start off

by thanking all the witnesses for being here today. Yesterday, Senator Biden, the chairman of the full committee, held a hearing on

the future of the United States bilateral and also multilateral response to the HIV/AIDS crisis, and I certainly commend him for

elevating this issue to the appropriate level and for making plain

that this crisis is truly one of the most urgent foreign policy priorities we confront today. We are very fortunate that the chairman

has used his leadership position in this way to face this tremendous crisis.

Today, the committee will focus on Africa, where the crisis is

most severe, to take stock of what we have learned and what we

still do not know about how to most effectively pursue prevention,

care, and treatment in the region. According to UNAIDS December

2001 AIDS epidemic update, 2.3 million African people died in 2001

because of AIDS. The estimated 3.4 million HIV infections in subSaharan Africa in the past year mean that 28.1 million Africans

now live with the virus.

The report states that recent antinatal clinic data show that several parts of southern Africa have now joined with Botswana with

prevalence rates among pregnant women exceeding 30 percent. In

West Africa, at least five countries are experiencing serious

epidemics, with adult HIV prevalence exceeding 5 percent. In

South Africa alone, an estimated 6 million people are infected. Approximately 2,300 more are infected every day. Over 260,000 will

die this year because of AIDS.

Anyone in the hearing room or watching that hearing yesterday

could not help but be impressed with the knowledge and commitment of my partner on the African Affairs Subcommittee, Senator

Frist. Senator Frist cares deeply about this issue and so do I. Both

of us have seen the individual tragedies that make up these horrifying statistics. We have spoken to the orphans and the widows

114

and the widowers. We have seen the terrible evidence of pervasive

death in too many African communities, but we have also seen

ample evidence that the situation is not a hopeless one.

In Uganda, an aggressive campaign with support from the highest levels of government is bringing infection rates down. In Senegal last year, I had the pleasure of meeting with that country’s visionary public health community, which includes tireless volunteers and dedicated scientists, doctors and nurses, and clerics who

are raising awareness in mosques throughout the country.

Let me be clear, Africans themselves provide the help and inspiration that one needs to confront a crisis of this magnitude headon. I often recall the very end of my inspirational meeting in Senegal. A gentleman who had been waiting very patiently among

those briefing me stood up and, speaking softly, he told me that he

is HIV positive. He wanted to know if there would be any help for

him, any assistance with the kind of treatment that is out of reach

for so many in Africa.

There must be an answer to his question. Increasingly, the world

is recognizing that treatment is a critical component of the fight

against AIDS. Statistics from Botswana suggest that when treatment comes available, voluntary testing and counseling rates surge

upward.

One of the witnesses yesterday stressed the importance of integrating tuberculosis screening with HIV/AIDS testing so that people who come in for the HIV test can also learn their TB status

and at the same time be referred to a treatment center. In these

scenarios, prevention and treatment complement and reinforce

each other, increasing the impact of the overall effort. But pursuing

both treatment and prevention means making choices, choices

about resource allocation, about public health strategies and, indeed, about treatment options themselves.

As Senator Frist reminded the committee yesterday, there are a

range of options covered by the broad category of treatment, including options specifically targeted to opportunistic infections. It

seems clear to me that some of these choices will vary from one

community to another, depending upon the context on the ground.

How we assess that context, how we make those choices together

with our African partners, these are the topics that I hope we will

explore today. They are difficult and complicated questions, but one

thing is perfectly clear and simple, and that is that there is a moral

imperative to act. There are unquestionably other reasons to act,

most notably to protect our security interest, because devastated

societies are unstable societies. The U.S. Institute of Peace recently

issued a report highlighting the connection between HIV/AIDS and

conflict in Africa, and the economic drain of a disease that affects

the most productive segment of society is setting back hard-won

gains in poverty reduction.

But to explain the sense of urgency surrounding this issue I

think it is enough to return to the basic human decency that tell

us that we cannot stand by as tens of millions die and societies collapse. That clarity guides all of us as we wrestle with issues that

are anything but clear, and so I look forward to the testimony

today.

[The prepared statement of Senator Feingold follows:]

115

PREPARED STATEMENT OF SENATOR RUSSELL D. FEINGOLD

I want to start out by thanking all of the witnesses for being here today. Yesterday Senator Biden, the Chairman of the full committee, held a hearing on the future

of the U.S. bilateral and multilateral response to the HIV/AIDS crisis. I certainly

commend him for elevating the issue to the appropriate level and for making plain

that this crisis is truly one of the most urgent foreign policy priorities that we confront today.

Today, the committee will focus on Africa, where the crisis is most severe, to take

stock of what we have learned and what we still don’t know about how to most effectively pursue prevention, care, and treatment in the region. According to

UNAIDS’ December 2001 AIDS Epidemic Update, 2.3 million African people died in

2001 because of AIDS. The estimated 3.4 million new HIV infections in sub-Saharan

Africa in the past year mean that 28.1 million Africans now live with the virus. The

report states that ‘‘recent antenatal clinic data show that several parts of southern

Africa have now joined Botswana with prevalence rates among pregnant women exceeding 30%. In West Africa, at least five countries are experiencing serious

epidemics, with adult HIV prevalence exceeding 5%.’’ In South Africa alone, an estimated 6 million people are infected. Approximately twenty-three hundred more are

infected everyday. Over two hundred and sixty thousand will die this year because

of AIDS.

Anyone in the hearing room or watching that hearing yesterday could not help

but be impressed with the knowledge and commitment of my partner on the African

Affairs Subcommittee, Senator Frist. Senator Frist cares deeply about this issue,

and so do I. Both of us have seen the individual tragedies that make up the horrifying statistics, we have spoken to the orphans and the widows and the widowers,

we have seen the terrible evidence of pervasive death in too many African communities.

But we have also seen ample evidence that the situation is not a hopeless one.

In Uganda; an aggressive campaign with support from the highest levels of government is bringing infection rates down. In Senegal last year, I had the pleasure of

meeting with that country’s visionary public health community, which includes tireless volunteers, dedicated scientists, doctors and nurses, and clerics who are raising

awareness in mosques throughout the country. Let me be clear—Africans themselves provide the hope and inspiration that one needs to confront a crisis of this

magnitude head-on.

I often recall the very end of my inspirational meeting in Senegal. A gentleman

who had been among those briefing me stood up, and speaking softly, he told me

that he is HIV positive. He wanted to know if there would be any help for him, any

assistance with the kind of treatment that is out of reach for so many in Africa.

There must be an answer to his question. Increasingly, the world is recognizing

that treatment is a critical component of the fight against AIDS. Statistics from Botswana suggest that when treatment becomes available, voluntary testing and counseling rates surge upward. One of the witnesses yesterday stressed the importance

of integrating tuberculosis screening with HIV testing, so that people who come in

for the HIV test can also learn their TB status and at the same time be referred

to a treatment center. In these scenarios, prevention and treatment complement and

reinforce each other, increasing the impact of the overall effort.

But pursuing both treatment and prevention means making choices—choices

about resource allocation, about public health strategies, and indeed about treatment options themselves. As Senator Frist reminded the committee yesterday, there

are a range of options covered by the broad category of treatment, including options

specifically targeted to opportunistic infections. It seems clear to me that some of

these choices will vary from one community to another, depending upon the context

on the ground. How we assess that context, how we make those choices together

with our African partners—these are the topics that I hope we will explore today.

These are difficult and complicated questions. But one thing is perfectly clear and

simple, and that is the moral imperative to act. There are, unquestionably, other

reasons to act—most notably to protect our security interests, because devastated

societies are unstable societies. The U.S. Institute of Peace recently issued a report

highlighting the connection between HIV/AIDS and conflict in Africa. And the economic drain of a disease that affects the most productive segment of society is setting back hard-won gains in poverty reduction. But to explain the sense of urgency

surrounding this issue, I think it is enough to return to the basic human decency

that tells us that we cannot stand by as tens of millions die and societies collapse.

That clarity guides all of us as we wrestle with issues that are anything but clear.

I look forward to the testimony today.

116

Senator FEINGOLD. Now, I would like to turn to our ranking

member of the subcommittee, Senator Frist.

Senator FRIST. Thank you, Mr. Chairman, and welcome to all of

the witnesses in all three panels today. Especially, I thank all of

you for the work you are going to be talking about, and that is represented by your presentations and discussions today.

As the chairman said, if you look over the last 24 hours, most

of the hours, or working hours, have been spent addressing HIV/

AIDS, which I think hopefully makes a statement to others and to

the outside world how important this issue is to this subcommittee,

to this Foreign Relations Committee, and to this Government in

the United States today.

The statistics, we all start and go through the statistics, and it

is tempting to move on beyond them, but when you realize that

every 10 seconds one person dies from AIDS, and another two are

infected, and we have no cure for that infection, you realize that

we are on a curve that can result in devastation and destruction

of a generation, or if we do it right, if we provide the right leadership, if we have the appropriate strategy and planning, we can reverse what we all project out to be a continuation of the most devastating, most destructive health, yes, public health, but health crisis that mankind has ever seen.

In January I went to Africa, and there are several people actually in the room today, Scott and Tricia Hughes, who was with me,

as we look predominantly at HIV/AIDS programs just now. Three

weeks ago we had the opportunity to travel to Nairobi, where we

visited the Kaberra slum, 750,000 people with one out of five of the

individuals in that community HIV positive. As we walked through

the crowds, as we walked down the streets, they are—most of you

have seen pictures of the narrow passageways there, with the

shanties and the aluminum roofs. You just did not see that many

people of middle age. You saw very young people and you saw older

people, but you see first-hand the devastation, with a whole middle

sector of the generation of people now gone, a sector of people that

are among the most productive in terms of their working lives,

being teachers, participating in the military.

We had the opportunity to go to Tanzania, to Arusha, where we

met Nema, who—I mentioned this in the hearing yesterday—

means ‘‘Grace,’’ and is HIV/AIDS positive. She sells bananas on the

side to survive, and to provide for her little year-and-a-half old son.

When that son, as we visited, cried from hunger, she really had

nothing else, nothing else to offer except a kiss on that little hand.

Marguerite, in Arusha, whose symptoms first came on in 1990,

her husband died, and despite her illness she found the strength

to fight his family in order to keep the family property, and thanks

to her brother she has a house for her six children.

Tabu, a 28-year-old prostitute who was leaving Arusha to return

to her village to die. She stayed an extra day so she could meet

with us, so we could visit with her, and I will never forget her

cheerful demeanor, her smile as we met her in a small hut 12 x

12 feet in size. Her two sisters, also infected, another sister has already died, and Tabu, who by now has probably died, will have left

behind an 11-year-old daughter, and the stories go on and on.

117

We must fight this battle on two fronts, prevention and expanding access to treatment. Science will provide a vaccine, I think, at

some point in the future, and it is a goal that we must all strive

to. In the meantime, prevention, care, other types of treatment

should be underway. Behavioral change is key. Even in HIV-ravaged Africa, most of those who come in today will be negative. As

we all know, however, that 8 out of 10, or 9 out of 10 in Africa

today do not know whether they are negative or positive.

Rapid HIV testing in many ways has revolutionized, I believe,

the opportunity we have to reverse the trends from the last several

years in Africa. A test that is specific, maybe not so sensitive, combined with a test that is sensitive and perhaps not so specific, but

together for less than $1—or about $1 a test—someone can come

in, be counseled, 50 minutes later have the results of that test,

complete counseling, and we know that this voluntary counseling

and testing works.

A huge challenge, a challenge that seems insurmountable, but

being on the ground, looking at the programs that work, sharing

those stories as to what works, increasing investment where we

know that things work, I am convinced can make a difference.

In yesterday’s testimony we heard a lot of encouraging news

about prevention and treatment, news that we will share with our

colleagues. We were able to visit 2 weeks ago centers of success like

the AID Information Center in Uganda, which is a USAID-funded

project, the Kikoshep project in Nairobi, a Centers for Disease Control and Prevention [CDC] CDC-funded project, and you can see the

differences that they make. I am encouraged by the good work of

USAID, encouraged by the good work of the CDC in Africa. We can

do a lot more.

Dr. Peter Piot was with us yesterday, as you have heard. As stated, the scourge of AIDS has been with us for 20 years, but it is

a tale that is still in its opening chapters. It will take all of our

efforts, public and private, pulling together partnerships, individuals, churches, denominations of all faiths, to tackle this problem.

I look forward to hearing our witnesses today, and appreciate all

of them taking time to share their experiences with us.

[The prepared statement of Senator Frist follows:]

PREPARED STATEMENT OF SENATOR BILL FRIST

I would like to thank our witnesses here today and especially thank them for all

the work they do every day to fight this terrible disease.

We are all aware of the alarming statistics:

• 22 million persons have already died of HIV/AIDS.

• 2.3 million died in Africa last year of HIV/AIDS.

• 13 million African children have already lost a parent to HIV/AIDS and this

number could be as high as 40 million by the end of the decade.

• 40 million persons are living with HIV/AIDS today, one third of the adults in

Botswana, Lesotho, and Swaziland are infected.

• 95 percent of those infected live in the developing world, and 90 percent of those

do not know they are infected.

• Every 10 seconds, one person dies from AIDS and nearly two more are infected.

In January, I went to Africa and witnessed the human face of these statistics. In

Nairobi, Kenya, I visited the Kibera slum. With a population of over 750,000, one

out of five of those who live in Kibera are HIV/AIDS positive. As I walked the

crowded, dirty pathways sandwiched between hundreds of thousands of aluminum

shanties, I was amazed that everyone was a child, or very old. The disease had

118

wiped out the parents—the most productive segment of the population—teachers,

military, workers, the providers.

In Arusha, Tanzania, I met Nema whose name means ‘‘Grace.’’ She sells bananas

to survive and provide for her year-and-a-half-old son, Daniel. When Daniel cried

from hunger, Nema kissed his hand because she had nothing to give him but her

love.

Margaret, also in Arusha, had symptoms that first appeared in 1990. When her

husband died, despite her illness, she found the strength to fight his family to keep

the family property. Thanks to her brothers, she has a house for her six children.

And Tabu, a 28-year-old prostitute, who was leaving Arusha to return to her village to die. She stayed an extra day to meet with us, and I will never forget her

cheerful demeanor and mischievous smile as we met in her small stick-framed mud

hut, no more than 12 by 12. Her two sisters are also infected, another sister has

already died. Tabu will leave behind an eleven-year-old daughter, Adija.nnnn

These stories of a lost generation—of young mothers and their children are— sadly—not unique to Africa.

We must fight this battle on two fronts: by improving primary prevention and expanding access to treatment.

Until science produces a vaccine, prevention through behavioral change is the key.

Even in HIV ravaged Africa, most of those who come in to be tested will test negative. This presents a real opportunity to save countless lives. I believe we should

increase investments in rapid HIV testing kits and counseling for developing countries. Access to inexpensive and rapid HIV testing can help reinforce prevention

messages and guide treatment options. And as I saw in Africa, testing centers become centers of hope for the community, a place where those struggling with HIV/

AIDS can share ideas, support each other, learn important coping strategies, and

receive medical treatment and nutritional support.

Treatment is an important part of the mix. Treatment includes a mix of options

that not only suppress the virus but also stave off opportunistic infections and relieves suffering. For example, treatment can include not only antiretrovirals but also

nutritional support, antibitoics, and low-cost herbal and other medications to improve quality of life. When persons with AIDS receive medical and nutritional support, they live longer and healthier, avoiding opportunistic infections such as tuberculosis; providing income for themselves and their families; and ensuring a better

future for their dependents.

Prevention and treatment compliment each other. Without prevention, the disease

will continue to spread. The hope of treatment will bring people to get tested, reinforcing prevention efforts.

In yesterday’s testimony, we heard encouraging news that our efforts at prevention and treatment are making a difference to millions of Africans. I have been to

such centers of success as the AIDS information center in Uganda (a USAID funded

project) and the KICOSHEP project in Nairobi (a CDC funded project) and I have

seen the difference they can make. I am encouraged by the good work of USAID

in Africa and the CDC’s efforts in developing guidelines that will lower the cost of

medicines and testing so that they will be available to all who have this disease.

But we can do much more. As Dr. Peter Piot, who testified before this committee

yesterday has stated that the scourge of AIDS has been with us for twenty years

but it is a tale that is still in its opening chapters. It will take all our efforts—the

public and the private sectors, individuals, churches and denominations of all faiths

to tackle this problem.

I look forward to hearing from our witnesses on how we can further these efforts

and bring hope and relief to millions of Africans.

Senator FEINGOLD. Thank you, Senator Frist, for your eloquent

comments and for your obvious devotion to this issue. We appreciate it.

We have two outstanding panels of witnesses here today, so let

me make the introductions brief to give us time to discuss the incredibly important issues before us. Let me say that there could be

a vote in a few minutes, in which case we will just take a 10-

minute break and come right back and continue the proceedings.

Let me begin by introducing both witnesses on the first panel,

then I would ask each witness to testify in the order of introduction. First, Dr. Eugene McCray. Dr. McCray is the director of the

Global AIDS Program at the National Center for HIV, STD, and

119

TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia. The Global AIDS Program coordinates the CDC response to the global HIV/AIDS pandemic worldwide. This involves

a collaboration with the United States Agency for International Development in 24 countries in Africa, Asia, the Caribbean, and Latin

America.

Since 1988, Dr. McCray’s work at the CDC has focused on HIV

and tuberculosis surveillance both in the United States and internationally. He serves as a consultant to such agencies as the World

Health Organization and the International Union Against Tuberculosis, and he has worked on tuberculosis and HIV/AIDS projects

in a number of countries in southern Africa.

He has published a number of articles on tuberculosis and HIV/

AIDS, and he has received numerous awards for his scientific and

public health contributions. He is also a practicing infectious diseases physician, providing volunteer services in a primary care

clinic for HIV-infected persons.

Dr. Anne Peterson. Dr. Peterson is the Assistant Administrator

in USAID’s Bureau of Global Health. Dr. Peterson provides health

leadership at USAID, including technical and program support to

field interventions in the area of HIV/AIDS infectious disease, reproductive health, child and maternal health, environmental

health, and nutrition.

Before joining USAID, Dr. Peterson served for 3 years as Commissioner of Health for the State of Virginia. Dr. Peterson also has

an extensive background in both the U.S. and international public

health practice. She has served as a consultant for the Centers for

Disease Control and Prevention and the World Health Organization, and she has spent almost 6 years in Kenya and Zimbabwe

supporting community development, public health training and

AIDS prevention programs.

She is also the author of numerous scientific publications, and

speaks extensively on a wide range of health issues.

So with that, Dr. McCray, we would love to hear from you.

STATEMENT OF DR. EUGENE McCRAY, DIRECTOR, GLOBAL

AIDS PROGRAM, NATIONAL CENTER FOR HIV, STD, AND TB

PREVENTION, CENTERS FOR DISEASE CONTROL AND PREVENTION, ATLANTA, GA

Dr. MCCRAY. Thank you, Chairman Feingold and Dr. Frist,

members of the Subcommittee on African Affairs. I am pleased to

be here today to discuss the efforts of the Centers for Disease Control and Prevention to address HIV/AIDS worldwide and in particular in Africa, with a special focus on the necessary balance on

prevention and treatment. My remarks will be mainly about the

Global AIDS Program, or GAP, at CDC, but also touch in other

areas of CDC that are involved in HIV/AIDS internationally.

At the outset, I would like to acknowledge that we at CDC are

grateful, Mr. Chairman, to you and your colleagues on the subcommittee and the full Foreign Relations Committee for your support of these efforts, and I want to thank you for that.

I will not bore you with statistics that I think you are all familiar

with, but today I would like to outline for you what CDC, in conjunction with other U.S. Government entities, as well as numerous

120

other partners, is doing to intervene in this epidemic worldwide.

The hardest-hit region by far is sub-Saharan Africa, which accounts for 70 percent of all the HIV/AIDS cases, followed by southeast Asia, Latin America, and the Caribbean. CDC has concentrated its efforts in the 24 countries in those regions. A 25th

country, China, will be added probably by the end of this fiscal

year. We are working intensely with the governments of these nations to bring the epidemic under control. In fiscal year 2003, our budget for GAP was $143.7 million. Guided by its 5-year HIV prevention strategic plan, CDC works to

mount space for primary prevention programs, as well as treatment programs, initiatives, in collaboration with USAID, with

Health Resources and Services Administration [HRSA], NIH, and

the Department of Defense and the Department of Labor, and a

number of other countries. In addition, we are working with a

number of multilateral agencies such as the World Bank, WHO,

UNAIDS and so on, and soon the Global Fund for AIDS, TB and

Malaria. We are also working with private foundations such as the

Bill and Melinda Gates Foundation, and with a variety of international and nongovernmental organizations.

With the advice and assistance of our many partners, CDC has

developed a set of 17 technical strategies for implementing programs focusing on three key areas. These areas include infrastructure and capacity development, primary prevention, and care and

treatment, and I would like to talk a little about each of these

areas before turning to the question of balancing prevention and

treatment.

First, let me talk a little about infrastructure and capacity development. Most developing nations lack the necessary infrastructure

to adequately address their HIV/AIDS epidemic. Disease surveillance systems and epidemiology are often not comprehensive, making it difficult, if not impossible many times to accurately determine how many people are at risk for infection, what their risks

are, and the level of need for prevention services, as well as how

many people are already infected, which populations are involved,

and the need for care and treatment.

CDC provides funding and technical assistance to ministries of

health and other organizations to bolster essential laboratory services as well as improve quality assurance and quality control for

HIV testing. We provide training of laboratory personnel, as well

as purchase the needed equipment to ensure the labs are functioning at a minimal level.

The importance of a functioning public health and health care

delivery infrastructure to comprehensive HIV prevention care and

treatment programs cannot be overstated. Sound infrastructures

are essential to delivering needed services over time. For example,

voluntary counseling and testing or VCT is the cornerstone for prevention, and the gateway to care and treatment, but if the procurement systems fail to provide the needed test kits in insufficient

quantities an on-time VCT cannot be done.

If the laboratory system fails for lack of proper equipment, supplies, or trained personnel, tests cannot be performed and interpreted. If information infrastructure fails, individuals anxiously

awaiting test results cannot get them. Prevention opportunities,

121

both for those who are seronegative but at high risk, and for those

who are already infected, are lost as a result.

Likewise, the health care infrastructure can impede or support

care and treatment efforts. Training for health care providers,

equipment, drugs, and other essential components must be in place

and remain there over time for care and treatment programs to

succeed.

We in the developed world take these things for granted. In the

countries where we work, these are not a given. Capacity infrastructure development are critical first component of every GAP

program we are implementing.

Prevention, let me talk a little about prevention. Currently, a

safe and effective vaccine is not available, but when available will

contribute significantly, I think, to controlling the AIDS pandemic,

but while we have made tremendous progress in vaccine development, the development of a vaccine is likely years away. Other biomedical intervention such as vaginal microbicides are likewise as

yet not yet proven and ready for widespread use, so in the interim

the world’s best and only hope for controlling this epidemic is

through sound prevention and care programs.

CDC offers technical assistance and funding for a variety of prevention activities, including averting mother-to-child transmission

and intervention for special populations at high risk for acquiring

HIV, including in and out of school youth, teacher and other school

staff, injecting drug users, sex workers and their clients, and displaced populations.

Preventing mother-to-child transmission is a high priority for

most developing nations, and is the only proven opportunity to use

drug therapy to avert transmission from one person to another.

CDC works in concert with host countries, the National Institutes

of Health, and other partners to mount effective programs to provide necessary drug therapy to pregnant and post partum women

and their newborn, and to promote replacement feeding strategies

to avoid transmission via breast milk.

Another innovative program sponsored by CDC looks at ways to

effectively integrate prevention of HIV, other sexually transmitted

infections, and unintended pregnancies, and reproductive health

care. We know prevention works. We also know that to be effective

a prevention program must be mounted on a large scale. They cannot be scatter-shot, and they must be sustained over time. With

those conditions met, prevention programs can help countries contain and even reverse the growing epidemic.

For example, the Uganda national response to HIV has been recognized as a model program and the effort there has clearly curbed

the epidemic. Uganda’s sustained efforts have reaped enormous

benefits, and over the last decades we have seen consistent declines

in HIV prevalence reported through most of the surveillance systems in that country.

Next, let me turn to care and treatment. CDC’s treatment and

care activities focus on tuberculosis and other opportunistic infections, and more recently technical assistance on antiretroviral

therapies. For the past two fiscal years, CDC has provided a minimum of $3 million annually to HRSA for training and in-country

health care providers and safe and effective patient care and moniVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00125 Fmt 6601 Sfmt 6602 77846.002 SFRELA2 PsN: SFRELA2
122

toring. Working together, the two agencies are fostering hospital

and clinic-based programs as well as community and home-based

care for people living with HIV and AIDS.

Given that most developing countries lack the sophisticated medical monitoring equipment and tests available in the United States

and other developed nations, CDC and HRSA are also examining

the safety and effectiveness of what is known as syndromic management of HIV disease, which means that diagnosis and continuing care are based upon observable signs and reported symptoms, rather than sophisticated lab tests. Here in the U.S., patients’ viral load is monitored along with their T-cell count, both indications of the effect HIV is having on the body and therefore on

the patient’s health, but these tests are not feasible in most countries where CDC and HRSA work.

In such situations, clinicians have to manage patient care mostly

by look, touch, and feel, and these skills can be taught. Tuberculosis presents special dangers to those who are HIV-infected, and

CDC focuses particular attention on TB research, prevention, and

control. Research conducted by CDC and the Botswana ministry of

health shows that TB is a leading cause of death for HIV-positive

persons in Botswana, and another study showed that saliva tests

for HIV can be used in TB sputum specimens, offering an effective

tool for HIV surveillance in that population.

Let me state that none of the preceding activities that I mention

could be accomplished or even attempted without the integral cooperation and collaboration of other parts of the U.S. Government,

most particularly USAID, HRSA, NIH, as well as other partners.

Most importantly, the ministries of health play a major role in this.

Working together, our efforts are enhanced and multiplied so that

the whole is more than the sum of the parts.

Now I would like to focus on balancing prevention and treatment. With global infections at 40 million adult rates in some countries, close to 40 percent, there is no doubt that targeted, sustained

prevention efforts are critical. Lifelong prevention services are critical for those who are already infected with or without treatment.

Those that are not infected need support, information, and education to assist them to remain that way, and GAP country programs focus on prevention for individuals who are HIV-infected

and for those who are at high risk for becoming infected.

HIV is a top priority for most GAP countries. Faced with millions

of people in need of treatment, however, most of these countries

cannot afford these life-sustaining medications and the infrastructure required to deliver them safely and effectively, so in fiscal year

2001 the Congress, through the appropriations language, specifically directed CDC to support targeted antiretroviral treatment

demonstration projects in countries where sufficient care and treatment infrastructure exists.

Working in conjunction with USAID and academic institutions,

CDC is assessing ways to effectively, safely, and affordably bring

antiretroviral [ARV] treatment to countries and their people. The

global fund to fight TB and malaria, which has a tripartite focus

on prevention, care, and treatment, offers great promise, and CDC

looks forward to helping to implement these countries’ proposals

that are funded.

123

We know with absolute certainty the hope of treatment is a great

inducement to taking HIV tests and learning your serostatus, and

the test is the gateway to prevention, so for those who are

uninfected, post test counseling and entry into prevention service

can help them remain HIV-free. We also believe treatment can help

to destigmatize HIV and can further the aim of prevention. Stigma

associated with HIV/AIDS continues to profoundly affect prevention efforts, leading patients to deny their risk, avoid testing, delay

treatment if it is available, and suffer needlessly.

Senator FEINGOLD. We are going to have to go cast our votes. We

will just simply come back as soon as we can and continue with

your testimony. Thank you.

[Short recess.]

Senator FEINGOLD. The committee will come back to order. My

apologies for the delay. Dr. McCray, if you would like to finish your

remarks.

Dr. MCCRAY. Yes. I should be brief. I was just going to basically

state that recent successes in Ivory Coast and Uganda have demonstrated that antiretrovirals can be provided safely, effectively,

and appropriately in development countries, and we think that the

United States can help capitalize on these successes and at the

same time assist developing countries where appropriate to build

the infrastructure to safely and effectively provide these drugs and

help also create a lasting health infrastructure.

Let me just basically conclude by saying we clearly recognize the

enormous challenges that lie ahead, but we have hope and are supported by encouraging gains from programs that are already underway that our efforts will avert potential disaster. I think that we

are seldom presented with such clear and pressing need, and such

unambiguous means to intervene. I would like to thank you again

for your support of this important endeavor, and I would be happy

to take questions at the end.

[The prepared statement of Dr. McCray follows:]

PREPARED STATEMENT OF EUGENE MCCRAY, M.D., DIRECTOR, GLOBAL AIDS PROGRAM, CENTERS FOR DISEASE CONTROL AND PREVENTION, DEPARTMENT OF HEALTH

AND HUMAN SERVICES

Mr. Chairman, members of the Subcommittee on African Affairs, I am pleased to

be here today to discuss the efforts of the Centers for Disease Control and Prevention (CDC) to address HIV/AIDS worldwide and, in particular, in Africa, with a special focus on the necessary balance between prevention and treatment. My name is

Eugene McCray; I’m a physician and I direct the Global AIDS Program (GAP) at

CDC. My remarks will be mainly about the GAP program, but also touch on other

areas of CDC that are involved in HIV/AIDS internationally.

At the outset, I would like to acknowledge that we at CDC are grateful, Mr.

Chairman, to you and your colleagues on this subcommittee, and larger Foreign Relations Committee, for your support of these efforts. Thank you.

CURRENT SITUATION

The World Health Organization and the Joint United Nations Programme on HIV/

AIDS report that 40 million people worldwide are now living with HIV/AIDS. About

3 million people died of AIDS in 2001 and slightly more than 5 million became infected—or almost 14,000 a day, every day, for the entire year. More than 95% of

the new infections are in developing countries. Of the 14,000 infected daily, about

12,000 are people aged 15 to 49 years—and about half are young adults ages 15

to 24. Almost 6,000 are women (Figure 1).

124

FIGURE 1

In areas of some countries, as many as 40% or more of the adult population is

infected with HIV. Health care services, including treatment for HIV/AIDS and its

associated illnesses, such as tuberculosis, are extremely limited. Look around this

room. Imagine if half the people here today were infected with a deadly disease,

doomed to die slowly and painfully and, in many instances, without care and support (Figure 2). In fact, WHO and UNAIDS estimate that nearly 22 million people

have died since the beginning of the pandemic, most of them in the developing

world.

125

FIGURE 2

These statistics don’t begin to represent the devastation AIDS wreaks upon the

developing world. Just this week, at the African Population Commission meeting in

Addis Ababa, it was reported that life expectancy of Africans is set to reach one of

its lowest levels ever. By 2005, most Africans will die before they reach their 48th

birthday. The spread of HIV/AIDS in particular, along with wars and poverty, have

driven down life expectancy by 15 years in the last two decades. Unchecked, AIDS

has the potential to destabilize national economies and social systems, to throw nations into a spiral of instability and civil unrest, and, possibly, to draw the United

States and other developed countries into national and regional conflicts. But we

have the opportunity and, I would argue, the responsibility to intervene. Today I’d

like to outline for you what CDC, in conjunction with other U.S. Government entities as well as numerous other partners, is doing to intervene.

126

RESEARCH

In the research arena, capitalizing on its 20-year history of international prevention research, CDC’s established field stations in countries such as Uganda, Kenya,

Cote d’Ivoire, Botswana, South Africa, and Thailand are working with the National

Institutes of Health and local researchers in three key areas: preventing mother-tochild transmission, field testing a vaginal microbicide, and collaborating on trials of

candidate HIV vaccines, including the development of relevant cohorts of trial participants. For example, CDC will soon have a senior researcher stationed in Botswana to head up an investigation of the effectiveness of an innovative microbicide

made from a seaweed component. CDC’s long history of work with the Ministry of

Health in Botswana means that, if this product is shown to be effective, it can be

swiftly deployed in the field, to help women protect themselves against sexual transmission of HIV. CDC would also utilize the GAP infrastructure to extend this product to women in other countries, as it becomes commercially available.

A safe and effective HIV preventive vaccine is essential to controlling the AIDS

pandemic. But, while we have made tremendous progress in vaccine development,

the deployment of a vaccine is likely years away. Other biomedical interventions,

such as microbicides, are likewise as yet not proven and ready for widespread use.

In the interim, the world’s best—and only—hope for controlling the epidemic is

through sound prevention programs.

PREVENTION PROGRAMS

Approximately 40 million individuals are now living with HIV worldwide. The

hardest-hit region, by far, is sub-Saharan Africa, which accounts for 70% of all HIV/

AIDS cases, followed by South and Southeast Asia, Latin America and the Caribbean. In total, those areas account for 90% of the world’s HIV/AIDS burden. CDC

has concentrated its efforts in 24 countries in those regions (China will be added

in Fiscal Year 2002), working intensively with the governments of these nations to

bring the epidemic under control (Table 1).

TABLE 1

COUNTRIES SERVED BY CDC’S GLOBAL AIDS PROGRAM FY2002

Angola Mozambique

Botswana Namibia

Brazil Nigeria

Cambodia Rwanda

China (new for FY 2002) Senegal

Cote d’Ivoire South Africa

Democratic Republic of Congo Tanzania

Ethiopia Thailand

Guyana Uganda

Haiti Vietnam

India Zambia

Kenya Zimbabwe

Malawi Regional: CAREC (Caribbean Epidemiology Centre)

CDC’s GAP, currently has 38 staff stationed in 17 of those countries, we hope to

add staff to the remaining 8 by mid-year. The fiscal year 2003 budget for GAP is

$143,763,000.

Guided by its five-year HIV Prevention Strategic Plan, and through GAP, CDC

works to mount science-based primary prevention programs as well as care and

treatment initiatives in collaboration with U.S. agencies such as USAID, NIH, the

Health Resources and Services Administration, the Department of Defense and the

Department of Labor here in the U.S.; with multinational agencies such as the

World Bank, WHO, UNAIDS, and, soon, the Global Fund to Fight AIDS, TB, and

Malaria; private foundations such as the Bill and Melinda Gates Foundation, and

a variety of international non-governmental organizations. With the advice and assistance of its many partners, CDC has developed a set of 17 technical strategies

for implementing programs, focusing on three key areas:

127

• infrastructure and capacity development, including disease surveillance, laboratory technical support, information systems, training, and program monitoring

and evaluation;

• primary prevention, including voluntary counseling and testing, preventing

mother-to-child transmission, blood safety, sexually transmitted disease prevention and care, behavior change communications, and prevention for drug users;

and

• care and treatment, including treatment of tuberculosis and other opportunistic

infections, palliative care, and appropriate use of antiretroviral medications.

INFRASTRUCTURE AND CAPACITY DEVELOPMENT

Most developing nations lack the necessary infrastructure to adequately address

their HIV/AIDS epidemics. Disease surveillance systems and epidemiology are often

not comprehensive, making it difficult if not impossible to accurately determine how

many people are at risk for infection, what their risks are, and the level of need

for prevention services, as well as how many are already infected, which populations, and the level of need for care and treatment. CDC provides funding and

technical assistance to Ministries of Health and other organizations working in GAP

countries (e.g., local nongovernmental organizations and international entities) to

bolster essential laboratory services, including quality assurance and quality control

for HIV testing, training for laboratory personnel, and purchasing needed equipment.

The importance of functioning public health and health care delivery infrastructures to comprehensive HIV prevention, care, and treatment programs cannot be

overstated. Sound infrastructures are essential to delivering needed services over

time. For example, voluntary counseling and testing (VCT) is the cornerstone of prevention and the gateway to care and treatment. But if the procurement system fails

to provide needed test kits in sufficient quantity and on time, VCT can’t be done.

If laboratory systems fail for lack of proper equipment, supplies, or trained personnel, tests can’t be performed and interpreted. If information infrastructure fails,

individuals anxiously awaiting test results can’t get them. Vital surveillance information is lost. Prevention opportunities—both for those who are seronegative but

at high risk and for those who are already infected—are lost. Likewise, the health

care delivery infrastructure can thwart or support care and treatment efforts. Training for health care providers, equipment, drugs, and other essential components

must be in place and remain there over time for care and treatment programs to

succeed. We take these things for granted in the developed world. In the countries

where GAP works, they are not givens. Capacity and infrastructure development are

critical first components of every GAP program in every country.

PREVENTION

CDC also offers technical assistance and funding for a variety of prevention activities, including averting mother-to-child transmission and prevention for special populations at high risk for acquiring or transmitting HIV, including in- and out-ofschool youth, teachers and other school staff, injecting drug users, sex workers and

their clients, and displaced populations.

For example, working with WHO, CDC has successfully brought together Ministries of Health and Education to work together to strengthen school-based HIV

prevention and to help prevent HIV/AIDS from decimating the ranks of teachers.

According to UNICEF, the United Nations Children’s Fund, HIV/AIDS incidence is

disproportionately high among teachers in sub-Saharan Africa. In Kenya alone,

nearly 1,500 teachers died from AIDS-related disease last year, up from just 10

deaths in 1993. The loss of large numbers of teachers in a poor nation is a serious

blow to future development. Unless the trend is reversed, a generation of young Africans faces the prospect of fewer education opportunities and reduced job prospects,

with corresponding negative effects on fragile country economies and social systems.

CDC also supports innovative projects aimed at helping women. Preventing mother-to-child transmission is a high priority for most developing nations—and is the

only proven opportunity to use drug therapy to avert transmission from one person

to another. CDC works in concert with host countries, NIH, and other partners to

mount effective programs to provide necessary drug therapy to pregnant and postpartum women and their newborns and to promote replacement feeding strategies

to avoid transmission via breastmilk. Another innovative program sponsored by

CDC looks at ways to effectively integrate prevention of HIV, other sexually transmitted infections (or STIs), and unintended pregnancy in reproductive health care.

Data from a large number of biologic and epidemiologic studies show that STIs

are a co-factor for HIV transmission. An untreated STI can increase both the acquiVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00131 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
128

sition and transmission of HIV up to fivefold. Thus, STI prevention and treatment

have the potential to play an important role in the reduction of sexually acquired

HIV transmission in addition to preventing the other consequences of STIs, such as

infertility and congenital infections. Based on country needs, available epidemiologic

and behavioral data, and ongoing activities by other partners, CDC focuses on developing and implementing programs that promote risk reduction behaviors; improve

STI health-seeking behaviors; strengthen availability and quality of and access to

STI treatment services; and increase services for vulnerable populations, particularly youth.

We know prevention works. Substantial evidence from carefully controlled scientific studies and from analyses of various developing countries’ experiences shows

that prevention is effective, and cost effective. We also know that to be effective,

prevention programs must be mounted on a large scale. They can’t be scattcrshot

and they must be sustained over time. With those conditions met, prevention programs can help countries contain and even reverse growing epidemics.

For example, in sub-Saharan Africa, Uganda’s national response to HIV/AIDS has

been recognized as a model program. The bedrock of this successful program is

strong commitment from national leaders, starting with the president. In 1986,

President Yoweri Museveni first highlighted the nation’s growing HIV epidemic; a

national AIDS control program was established the following year. In 1990, the

Uganda AIDS Commission was created under the president’s leadership and supports comprehensive prevention programming. This includes widespread voluntary

counseling and testing (VCT). Behavior change communications are implemented

through mass media, community-based organizations (CBOs), and schools. Faith

groups, including Roman Catholic, Protestant, and Islamic organizations, have

played an important role in providing educational materials and encouraging behavior change.

Uganda’s sustained effort has reaped enormous benefits. Over the last decade,

consistent declines in HIV prevalence were reported by most surveillance systems.

For example, in Kampala, the major urban center, data from prenatal clinics has

been available since the mid-1980s. Surveillance showed that HIV prevalence

among women attending prenatal clinics increased from 11% in 1985 to 31% in

1990. Beginning in 1993, however, HIV prevalence among this population began to

decline, reaching 14% in 1998. Outside Kampala, median HIV prevalence among

prenatal clinic patients has declined from 13% of those tested in 1992 to 8% in 1998.

Similar declines have been observed among patients at STD clinics. For example,

in 1989, 42% of male STD clinic patients in Kampala were HIV-positive; by 1992,

that had increased to 46%. In 1998, only 30% of male STD clinic patients were HIVpositive. In 1989, 62% of female STD clinic patients were HIV-positive; by 1997,

that had declined to 37%.

In addition to tracking HIV prevalence, behavioral surveillance also monitors people’s sexual behaviors, tracking changes in risky—and healthy—behaviors and in

people’s knowledge levels and attitudes. For example, Uganda tracks people’s knowledge of protective practices, numbers of and behaviors with non-regular sexual partners, condom use, age at first sexual experience, and adolescent pregnancy. All

these indicators help hone prevention messages and target populations most in

need. Uganda is a GAP country, and CDC staff are working with the government

and other partners to ensure that Uganda’s success continues and multiplies.

CARE AND TREATMENT

CDC’s treatment and care activities also include a focus on tuberculosis and other

opportunistic infections and, more recently, technical assistance on antiretroviral

therapies (ARVs). For the past two fiscal years, CDC has provided $3 million annually to the Health Resources and Services Administration for training in-country

health care providers in safe and effective patient care and monitoring. Working together, the two agencies are fostering hospital- and clinic-based care programs, as

well as community- and home-based care, for people living with HIV/AIDS.

Given that most developing countries lack the sophisticated medical monitoring

equipment and tests available in the U.S. and other developed nations, CDC and

HRSA are also examining the safety and effectiveness of what is known as

‘‘syndromic management’’ of HIV disease, which means that diagnosis and continuing care are based on observable signs and symptoms, rather than sophisticated

lab tests. Here in the U.S., patients’ viral load is monitored, along with their T-cell

counts, both indications of the effects HIV is having on the body, and therefore the

patient’s health. But these tests are not feasible in most countries where CDC and

HRSA work. In such situations, clinicians there have to manage patient care by look

and touch and feel—all skills that can be taught.

129

Tuberculosis presents special dangers to those who are HIV-infected, and CDC focuses particular attention on TB research, prevention, and control. For example,

with the Ministry of Health in Botswana, CDC has sponsored the BOTUSA project

since 1995. Research conducted by BOTUSA showed that TB is the leading cause

of death for HIV-positive persons in Botswana and another study showed that saliva

tests for HIV can be used on TB sputum specimens, offering an effective tool for

HIV surveillance. Additional studies are underway to assess a rapid TB diagnostic

test that is effective among HIV-positive persons; the optimal duration of TB treatment among those who are HIV infected; and the acceptability of directly observed

antiretroviral therapy for HIV.

None of the preceding activities could be accomplished or even attempted without

the integral cooperation and collaboration of other parts of the U.S. government,

most particularly USAID, as well as other partners. Working together our efforts

are enhanced and multiplied, so that the whole is more than the sum of its parts.

BALANCING PREVENTION AND TREATMENT

With global infections at 40 million and adult seroprevalencc rates in developing

countries of, in some instances, of higher than 40%, there is no doubt that targeted,

sustained prevention efforts are critical. It is self-evident: Estimates are that 14,000

people are infected daily. Lifelong prevention services are critical for those who are

already infected, with or without treatment. Those who are not infected need support, information and education, and assistance to remain that way. GAP country

programs focus on prevention for individuals who are HIV-infected and for those at

high risk of becoming infected.

HIV treatment is a top priority for most GAP countries. Faced with millions of

people in need of treatment, however, most countries cannot afford the cost of these

life-sustaining medications and the infrastructure required to deliver them safely

and effectively. In fiscal year 2001, Congress, through appropriations language, specifically directed CDC to ‘‘support targeted antiretroviral treatment demonstration

projects in countries where sufficient care and treatment infrastructure exist.’’

Working in conjunction with USAID, WHO, academic institutions like the Harvard

AIDS Institute, voluntary organizations, and the private sector, CDC is assessing

ways to effectively, safely, and affordably bring ARV treatment to desperate countries and their people. The Global Fund to Fight AIDS, TB, and Malaria (GFATM),

which has a tripartite focus on prevention, care and treatment, offers great promise

in this arena, and CDC looks forward to helping to implement those country proposals that are funded.

We know with absolute certainty that the hope of treatment is a great inducement

to taking HIV test and learning your serostatus. And a test is the gateway to prevention. For those who are uninfected, post-test counseling and entry into prevention services can help them remain HIV free. For those who are infected, prevention

services and support can help them avoid transmitting the virus to others. Without

the possibility of treatment or even palliative care, many people living in the dire

circumstances of the developing world simply have no reason to learn whether they

are infected or not. Treatment can help destigmatize HIV/AIDS and can further the

aims of prevention. Stigma associated with HIV/AIDS continues to profoundly affect

prevention efforts, leading people to deny their risk, avoid testing, delay treatment

if it is available, and suffer needlessly. AIDS stigma reflects societal biases about

race/ethnicity, socioeconomic status, sexual orientation, age, gender, and drug usc.

HIV infection evokes and magnifies these biases. But if HIV is no longer a death

sentence because of treatment, then the stigma associated with infection is likely

to diminish, supporting prevention efforts.

Various factors that must be considered in assessing how best to control the HIV/

AIDS epidemic are:

• Level of political will—What is the level of commitment from the country’s public and private-sector leadership to address prevention and treatment? What are

the host country’s priorities for epidemic control?

• Surveillance and epidemiologic information—What do we know about the populations who are infected, how and when they were infected, and the populations

at risk and why they are?

• Scalability of pilot or demonstration programs—What is the likelihood that

small-scale demonstration projects can be scaled up to a national level and sustained?

• Age of the epidemic—A country with a young epidemic, with low seroprevalence

rates and few cases of AIDS, may benefit more from prevention programming

than from treatment. As epidemics mature, with increases in seroprevalence

130

and AIDS cases, the mix of appropriate services will change, and treatment may

become a greater priority.

• Strengths and weaknesses of both the public health and health care delivery infrastructures—Can treatment efforts be safely mounted, without running the

risk of drug shortages? If procurement systems are inadequate, this may lead

to drug shortages, resulting in the inability of patients to maintain therapy

regimens, possibly leading to the development of drug-resistant strains of HIV,

as people cycle on and off medications or substitute less-effective drugs.

Recent successes in Cote d’Ivoire and Uganda demonstrate that ARVs can be provided safely, effectively, and appropriately in certain developing countries. Pilot programs in Uganda and Cote d’Ivoire addressed common concerns about providing

ARVs to people in developing countries, such as patients’ clinical response to treatment, ability to adhere to drug regimens, ability to stay in treatment, survival, the

emergence of drug resistance, and cost. In Uganda, patients were responsible for

payment for all their medical care, drugs and laboratory tests. There was no direct

financial support from the government or other donor agency. The outcomes were

better than expected and proved that sophisticated treatment programs can work

in developing countries. The United States can help capitalize on these successes

and, at the same time, assist developing nations, where appropriate, to build capacity to safely and effectively provide ARV treatment and create a lasting health infrastructure.

GAP’s guiding ethos on this topic is to view prevention and treatment as complementary and, where possible, integrated. Experience with preventing mother-tochild transmission demonstrates the value of integrating prevention services with

treatment. Thailand was the first developing country to implement a national program to prevent mother-child HIV transmission. As part of technical assistance

through the Global AIDS Program, CDC helped the Thai government develop a national hospital-based monitoring system, now implemented in >95% of Ministry of

Public Health hospitals. Data from >500,000 women giving birth in the first year

show that 93% had an HIV test, 70% of HIV-positive women received short-course

zidovudine (ZDV), and 82% of HIV-exposed children received infant formula. An estimated 1,000 infant infections were prevented. CDC is now assisting with other

projects to evaluate program outcomes, enhance HIV care for mothers and children

by including ongoing prevention, train health care workers, and research new interventions.

We recognize the enormous challenges that lie ahead. But we have abiding hope,

supported by encouraging gains from programs already underway, that our efforts

will avert potential disaster. We are seldom presented with such clear and pressing

need and such unambiguous means to intervene.

I thank you again for your support of this important endeavor, and I would be

happy now to take your questions.

Senator FEINGOLD. Thank you, Doctor, for your excellent testimony.

Dr. Peterson.

STATEMENT OF DR. E. ANNE PETERSON, ASSISTANT ADMINISTRATOR, BUREAU OF GLOBAL HEALTH, U.S. AGENCY FOR

INTERNATIONAL DEVELOPMENT [USAID], WASHINGTON, DC

Dr. PETERSON. I would like to thank you, Chairman Feingold and

Dr. Frist, for convening this important hearing and for inviting me

to testify. This is an area of long interest to me, after having lived

in Africa for almost 6 years and worked much of that time in the

area of HIV/AIDS. I have seen first-hand the devastation both in

individual and in collective lives due to AIDS. I will give some brief

remarks, and then I believe you have my longer written testimony.

Every country in the world has reported cases of HIV/AIDS. I

saw my first case of AIDS in Zaire in 1982, and then worked in

the mid-eighties in Kenya, when the adult prevalence of HIV was

well below 1 percent in the area we were living. Now, devastatingly, HIV/AIDS prevalence among adults exceeds 20 percent in

seven countries in the developing world, all in Africa, and was

131

above 10 percent in 9 additional countries and in another 41 countries prevalence equals or exceeds 1 percent. Twenty-two of these

are in Africa, 11 in Latin America, 4 in Asia, and 1 in Eurasia. As

you said, the burden of this disease is in Africa.

It is also not just different across the world, but it is also the epidemiology within the countries. Half of the new infections in Africa

are in the 15-to-24-year-old age group, and with young girls and

women, accounting for 75 percent of these. Over 80 percent of the

transmission is heterosexual, and over 55 percent of infections in

sub-Saharan Africa are occurring in women. This is due to both biological and socioeconomic vulnerability.

In parts of Kenya, 15 percent of 15-to-19-year-old girls are now

infected, compared to 6 percent of boys in the same age group. The

increasing number of infected women has led to nearly 600,000 infants becoming infected with HIV annually. Looking at this epidemiology, we need to recognize both the gender and geographic differences in the epidemiology of the disease. We do have simple

interventions to reduce mother-to-child transmissions that are

available, though currently less than 5 percent of women in subSaharan Africa have access to these services. These tragic statistics

are well-known to you all.

Since 1986, USAID has been addressing HIV/AIDS in developing countries, and has provided nearly $2 billion in support. I want to

also thank you for the increased funding that has come to USAID

in recent years. Our 2002 budget in the bilateral programs is $435

million for this year, with another $50 million for the Global AIDS

Fund, and we are expecting to be somewhere in the realm of $540

million for our bilateral programs for 2003 and another $100 million, as you have heard, was committed from our budget for the

global fund again.

We have HIV/AIDS programs in over 50 countries, of which 23

are receiving priority attention and a larger bulk of funding, 13 of

these priority countries are in sub-Saharan Africa, and as we are

looking at the resource allocation for the future, while not all of the

money is going to Africa, an increasing proportion of the money is

going to dealing with HIV/AIDS in Africa.

Responding to the scope and devastation of HIV/AIDS calls for

an extensive approach, from primary prevention to care and treatment, and finally, support for those infected and for the survivors,

especially for children orphaned by AIDS, and these include multisector initiatives. This is one of the comparative advantages for

USAID, that our prevention and treatment programs can be linked

with our other ongoing development efforts, both our school programs, agriculture, food, as well as the traditional maternal, child,

and other health programs.

Preventing new infections really continues to be the most urgent

priority in the fight against HIV/AIDS. Prevention programs are

designed to slow and ultimately reverse the rising HIV infection

rates, and we know they work, yet there is no single intervention

or magic bullet that can effectively deal with this pandemic.

Changing behavior is complex and difficult, and what works for one

person may not work for others.

All of the prevention initiatives we are talking about require behavior change by individuals, communities, and societies. We have

132

long experience that knowledge alone is not enough. It requires acknowledging personal risk, knowing how to avoid and reduce it.

That means close links to those individuals and those communities

to make the need for behavior change real and acted upon in their

lives.

We work with mobilizing society, providing skills to opinion and

religious leaders. We support intensive personal counseling and

HIV testing. That testing provides a teachable moment, an opportunity for intervention, social support, and increased knowledge

about the disease itself.

Many of you have heard about Uganda’s success story, and it

was mentioned yesterday, but we have success stories that are now

going beyond Uganda, and in Zambia there has been significant

delay in sexual debut, the age at which sexual intercourse begins,

by a full 1 to 2 years, a decreased number of sexual partners, and

increased condom use. We are seeing the success of those behavior

changes in reduced numbers of new infections.

Recent surveys show nearly a 50-percent reduction in prevalence

rates for the 15-to-19-year-olds in Lusaka and other urban areas

from 28 percent to 15 percent between 1994 and 1998. Prevention

is not easy, but it is working in many of the African countries. Prevention also links to medical interventions in the critical area of reducing mother-to-child transmission.

USAID now has programs in four countries, which include the

use of ARV to prevent transmission to the child. In Zambia we

focus on infant-feeding issues, in South Africa we fund 10 outreach

centers affiliated with Africa’s largest hospital, in Uganda we fund

testing and counseling, in Kenya we work with the Ministry of

Health. An important part of this effort is operations research, so

we can learn from the experience and share knowledge.

Finally, a review of USAID support of AIDS prevention would

not be complete without mention of our input into vaccine and

microbicide development. We recently finalized a 2-year, $16 million grant agreement with the international AIDS vaccine initiative, and for almost a decade we supported the development and

evaluation of microbicides to prevent sexual transmission of HIV/

AIDS. We plan to spend about $15 million in this area this year.

One promising microbicide is in the final stages of field testing, but

there is much more to the story than prevention alone.

More than 13 million children under age 15 have lost their mother or both parents due to AIDS. By 2010, some 44 million children

in 34 countries will have lost one or both parents primarily due to

AIDS. In sub-Saharan Africa, where the majority of AIDS orphans

resides, gains in health achieved over recent decades are unraveling. In Zimbabwe, I worked with street children orphaned by AIDS,

gave them medical care, and talked with them about the risk for

HIV/AIDS. I also taught AIDS prevention in schools, where the

children’s greatest fear was that they, too, would lose their parents.

Orphaned children lose their families, their hope for education,

basic necessities of food and shelter, they become easy prey for violence, sexual exploitation and crime. In some settings they are fodder for child militias. Again, in Zimbabwe, I worked with a local

NGO now funded, I found out later, by USAID that has an amazing program of community support to households that are headed

133

by teenagers. Facilitating such community support is the foundation of USAID’s support for children and families affected by AIDS.

Since 1999, USAID’s help for children has increased to more than

60 different projects in 22 countries.

These programs can have impressive impact. Care and treatment

is important for humanitarian reasons. It also enhances prevention

by increasing the utilization of voluntary counseling and testing, as

Dr. McCray said. It also prolongs parenthood and economic productivity.

By treating the most important opportunistic infections like tuberculosis, we extend the lives of persons infected with HIV. We

also help control the expanding TB epidemic which threatens all

countries, including our own.

People with HIV/AIDS have many needs in addition to health

care. These include psychological support, legal assistance, as Dr.

Frist mentioned, microenterprise opportunities, economic support,

and accurate information about HIV/AIDS. A USAID study found

that a person with HIV requires 10 to 15 percent more energy a

day and 50 to 100 percent more protein a day than an average

adult. We are now incorporating food security activities into our

care and support efforts. We currently have 25 care and treatment

projects overall in 14 countries.

Antiretroviral therapy is one of the more recent and controversial

areas, but it has had a dramatic impact in reducing AIDS mortality

in the developed world. There are challenges that limit the ability

to offer treatment and support to a large number of people, as Dr.

McCray again spoke to, that include the cost of the drug, which is

rapidly decreasing, but also treatment protocol and clinical capacity.

As our Administrator, Mr. Natsios, said yesterday, we are looking at having an introductory demonstration site for ARV usage.

We hope to be able to announce all of our sites during the course

of the next few months, but today the first site was finalized and

announced. This is since yesterday’s hearing. Ghana has launched

the START program. This program is in close partnership with the

Government of Ghana. It will introduce antiretroviral therapy as

part of a comprehensive HIV prevention and care program, and we

are one of the supporters of that through Family Health International.

This experience is not just a first-time for ARV use. It is also a

demonstration project that we can use the information for Ghana

and for other African Governments and donors, planning on how

best to provide care and treatment for people living with AIDS. We

will be launching three additional antiretroviral treatment demonstration sites in sub-Saharan Africa this year.

We need still to remember, as we enter into this new area, that

relying totally on treatment interventions will not stop the advance

of the pandemic. Lessons from the U.S., France, and Brazil and

other countries that offer ARV therapy clearly demonstrate that introduction of combination therapy does not retard the epidemic. We

must closely link our treatment with prevention.

The scope of the AIDS problem is immense. No one agency can

do all that needs to be done. We have many new partners who are

wanting now to participate in the AIDS problem, and we really

134

welcome that interest and concerted work, but with this many

partners, coordination of efforts becomes even more critical. It is

true among government agencies, and we have been working long

and well with CDC. It is also true in our international partners

and partnerships, including the new Global Fund.

The coordination efforts must occur at two levels, actually probably three, within Washington, at headquarters, in the international setting, and on the ground in each of the countries is probably the most vital. This kind of collaborative work is one of

USAID’s strengths.

In the past 2 years much progress has been made. We have

learned important lessons on what works and what does not. We

have successful models that are being replicated, and in six countries we are now seeing reductions in new HIV infections at the national, not just a program level. Drug costs have come down dramatically, and treatment protocols have been simplified. We have

tools, and we know they work, and with your continued support

and the new resources you have given us, we can move ahead to

save the lives of millions.

Thank you.

[The prepared statement of Dr. Peterson follows:]

PREPARED STATEMENT OF DR. ANNE PETERSON, ASSISTANT ADMINISTRATOR FOR

GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT

I would like to thank Chairman Feingold and Dr. Frist for convening this important hearing and for inviting me to testify.

Over the past twenty years the AIDS pandemic has continued to surprise, shock

and devastate us. Every country of the world has reported cases of HIV/AIDS. At

the dawn of this 21st century, HIV/AIDS prevalence among adults exceeded 20% in

7 countries in the developing world (all in Africa) and was above 10% in 9 additional

countries. In another 41 countries, prevalence equals or exceeds 1%. Twenty-two of

these are in Africa, eleven are in Latin America, four in Asia and one in Eurasia.

In contrast, HIV/AIDS prevalence in the United States was 0.6% at the end of 2000.

THE EPIDEMICS OF SUB-SAHARAN AFRICA

As we learn more about these epidemics, we discover that there is no single pattern.

• In the countries of East Africa, the oldest HIV epidemics in the world have occurred with slow, steady progression over the past 30 years. These are seen in

the Great Lakes regions of East Africa—in the countries of Uganda, Tanzania,

Malawi, Kenya, Zambia, and the Democratic Republic of the Congo (formerly

Zaire).

• In the countries of West Africa where the epidemic seems to have started about

10 years later, progression of the epidemic has been more indolent and is further complicated by the presence of both HIV 1 and 2. The national prevalence

rates are generally lower between 1 and 8%, except for Cote d’Ivoire, where the

prevalence is estimated to be over 10%.

• In Southern Africa where the epidemic started in the mid-to-late 80’s there

have been a series of explosive epidemics over the past 8 years, reaching the

highest prevalence levels on earth, 20-40%. These countries include South Africa, Namibia, Zimbabwe, Botswana, Swaziland, and Lesotho.

Specific aspects of the epidemics in this region include:

• Currently in Africa, half of new infections are in the 15-24 age group, with

young girls and women accounting for 75% of these. Over 80% of HIV transmission is heterosexual, with over 55% of infections in sub-Saharan Africa occurring in women. This is due to both increased biological and socio-economic

vulnerability.

• In parts of Kenya, fifteen percent of 15-19 year old girls are now infected compared with 6% of boys in the same age frame. Young girls are frequently infected by older men; these girls then infect their same age partners and husVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00138 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
135

bands as they get older; then the men as they get older in turn infect young

girls.

• The increasing number of infected women has led to nearly 600,000 infants becoming infected with HIV annually. While simple interventions to reduce mother-to-child transmission are available, currently less than 5% of women in subSaharan Africa have access to these services. This is primarily due to the shortage of systems capable of delivering this care. The challenge of preventing

mother-to-child transmission in Africa illustrates how difficult it can be to deliver even the simplest interventions in low resource settings.

These tragic statistics are well known to members of this Committee. Yesterday,

the Administrator for USAID shared USAID’s leadership role in fighting the pandemic. This has included developing the tools needed and providing direct assistance

to countries for prevention and care services. Since 1986, USAID has been addressing HIV/AIDS in developing countries and has provided nearly $2 billion is support.

In the late 80’s USAID’s programs were focused on prevention; in the mid-1990’s

USAID expanded its emphasis on sustainable prevention activities and launched

new programs in care, treatment and support for people and communities coping

with HIV/AIDS.

The HIV/AIDS pandemic presents some very special challenges. If one looks at

health interventions from a development perspective, there is an ongoing predisposition toward ‘‘public health’’ strategies. These often rely on relatively simple interventions. For example, in the areas of child survival to reduce infant and child mortality most international assistance revolves around immunizations, use of oral rehydration salts packets to treat diarrhea, and more recently, the use of vitamin A

to reduce infant mortality and impregnated bednets to reduce malaria transmission.

Interventions have generally cost between a few cents for an ORS packet and vitamin A, to $20 per person for immunizations to approximately $300 to cure a case

of TB.

HIV/AIDS IS DIFFERENT

Responding to HIV/AIDS calls for a radically different approach. We must address

multiple dimensions of the pandemic and recognize the essential synergies that enhance effectiveness of our investments. In developing country settings, we have

never attempted such a complex and comprehensive approach to a single disease—

from primary prevention to care and treatment and finally support for those infected and for survivors, especially children orphaned by AIDS. The necessary response is not limited to a single sector. We are drawing upon USAIDs broad development experience to design and implement multisectoral approaches. One of

USAID’s comparative advantages is that HIV/AIDS prevention and treatment can

be incorporated into other ongoing development assistance efforts, such as school

education programs and training of agricultural workers. Also very important is our

strong partnership with indigenous community organizations throughout Africa.

Prevention continues to be critical. However care and treatment are also critical.

Neither can be neglected.

We have HIV/AIDS programs in over 50 countries of which 23 receive priority attention. Thirteen of these priority countries are in sub-Saharan Africa.

A LOOK AT ACTUAL PROGRAMS

I would like to get down to specifics. What do our programs do in countries? How

do they actually work? I will give you some real examples from USAIDs country programs. Our programs fall into three broad areas: prevention; treatment/care/support; and children affected by AIDS. While all of these have substantial research

elements, which ensure that what we learn is quickly shared and applied, today I

will be focusing on the human impact of these programs.

PREVENTION EFFORTS

Preventing new infections continues to be the most urgent priority in the fight

against HIV/AIDS—currently about 70 percent of USAID’s HIV/AIDS budget is committed to prevention. Prevention programs are designed to slow—and ultimately reverse—rising HIV infection rates. We have now seen that these programs work in

countries where ARVs and other treatments are not available.

Yet, there is no single intervention or magic bullet that can effectively deal with

this pandemic. Changing behavior is complex and difficult and what works for one

person may not work for others.

There are two basic principles of prevention. The first is to reduce the frequency

of risky acts—by delaying the beginning of sexual activity and decreasing the numVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00139 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
136

ber of sexual partners. The second is to decrease the efficiency of HIV transmission—by treating sexually transmitted infections, and using condoms. We hope

that soon a microbicide will be developed that will help decrease the efficiency of

transmission. Ultimately, a vaccine will serve this purpose.

All of these interventions require behavior change by individuals, communities

and societies. Knowledge alone is not enough. Behavior change means far more than

having basic knowledge about the disease AIDS, or even being disturbed or concerned about it. It requires knowing one’s personal risk and how to lessen it. Promoting monogamy and condom use, and encouraging young people to wait, requires

mobilizing women, men, and communities to rethink policies and social norms. It

also involves creating environments where individuals who understand these messages are supported, not derided, shunned, or beaten. We have learned that HIV/

AIDS risk reduction needs positive social change that eliminates stigma and links

health, gender and human rights in new productive ways.

There are very important cultural factors which affect AIDS prevention programs.

We should not be so surprised then, that in the absence of such social change, even

in countries like Zimbabwe, Botswana, and South Africa, that have raging, visible

epidemics, people have continued in a state of denial about their own personal danger of becoming infected. The stigma that is associated with AIDS means that AIDS

is always someone else’s problem. We have seen this phenomenon in virtually every

country in the world—including our own.

To counter this lack of perceived personal risk, we are now mobilizing societies,

providing skills to opinion and religious leaders and supporting intensive interpersonal counseling and HIV testing. Giving the results of an HIV test provides an

opportunity for intervention, social support and increased knowledge about the disease itself.

Uganda shows how behavior can reverse a severe epidemic. There has been a

delay in sexual debut by one to two years, decreased numbers of casual partners

and increases in condom use. The proportion of Ugandan girls who have ever had

sex declined by almost half between 1989 and 1995. Over half of young sexually active Ugandans report using condoms in their last sexual contact—this rate was close

to zero at the outset of the epidemic. As a result of these two major changes in behavior, HIV infection rates among 15 to 19 year old girls have declined from 22 percent in the early 1990’s to 8 percent by 1998. In the same period, national HIV adult

prevalence has decreased from 14 percent to 8.3 percent.

In Zambia, we are also seeing the impact of behavior change on the number of

new infections. Recent surveys are showing nearly a 50 percent reduction in prevalence rates for the 15 to 19 year olds in Lusaka and other urban areas from 28 percent to 15 percent between 1994 and 1998.

Until the mid-1990s, women’s role in the AIDS crisis was little recognized. But

women now comprise nearly half of all infections—and in Africa, more than half.

In addition, women bear much of the burden of caring for HIV-infected family members and risk passing HIV on to their infants. They often also have the least control

over their risk of contracting AIDS, for both cultural and economic reasons. Because

USAID’s HIV/AIDS programs recognize the difficulties women and girls face, they:

• Work through maternal, child, and other health services that women use;

• Help women develop action plans to reduce their risk of HIV infection and to

increase their access to services;

• Address economic and social issues that put women at a disadvantage;

• Involve men as well as women in supporting the health and welfare of women

and girls;

• Involve women’s organizations in the fight against AIDS. For example, in Senegal, traditional women’s associations played a key role in increasing condom

use.

In addition to behavior change, we heed to apply what we have learned about

medical interventions to reduce transmission. One critical area involves reducing

mother to child HIV transmission. USAID now has programs in 4 countries.

• In Zambia, USAID supports an innovative community based program in Ndola

District that provides education on HIV and infant feeding choices and offers

referral to the district health center for testing and counseling. This program

is adding antiretroviral prophylaxis. This innovative model will be expanded to

Malawi this year.

• In South Africa, USAID is providing management support to the MTCT program at Chris Hani Baragwanath Hospital in Soweto. This hospital which performs 16,000 deliveries per year provides MTCT services to women delivering

137

in the hospital and has established MTCT services in more than 10 outreach

centers.

• In Uganda, USAID is supporting MTCT services in Mulago Hospital (in Kampala) along with the Elizabeth Glaser Pediatric AIDS Foundation. USAID funds

the testing and counseling components, while the hospital is providing the

antiretroviral drugs and antenatal care.

• In Kenya, USAID currently supports MTCT prevention projects in three sites.

This is a collaborative effort with the government of Kenya, UNICEF, UNAIDS,

WHO, and African researchers. An important part of this effort is a comprehensive operations research study, so that we can learn from the experience and

share the knowledge gained.

Another important way that we can reduce transmission is through treating other

sexually transmitted diseases (STIs). A study in Tanzania showed that treating

these infections, such as syphilis and chancroid, reduced HIV transmission by almost half. Treating STIs is a standard part of our HIV/AIDS prevention programs.

Recently we have begun applying an innovative approach, periodic presumptive

treatment, to those at very high risk, such as truck drivers, migrant workers and

prostitutes. This ensures that these populations get regular treatment even where

there is not sophisticated laboratory support.

Finally a review of USAID’s support to AIDS prevention would not be complete

without mention of our substantial investments in vaccine and microbicide development.

The pursuit of a vaccine that will prevent transmission of all strains of HIV remains one of the most challenging scientific and technological problems facing the

world today. USAID has finalized a two-year $16 million grant agreement with the

International AIDS Vaccine Initiative (IAVI). IAVI provides scientific leadership by

financing and managing promising international vaccine research and development

projects in developing countries. USAID’s funding will provide support for vaccine

research and development and strengthening clinical and laboratory infrastructure

in developing countries. Also because USAID has extensive developing country experience and on the ground infrastructure, we stand ready to partner with vaccine developers to facilitate the contacts with governments NGOs and academia that will

be needed for successful vaccine trials. We will provide assistance with community

preparation and mobilization and the necessary prevention interventions needed to

support AIDS vaccine trials.

USAID has been supporting the development and evaluation of microbicides to

prevent sexual transmission of HIV for almost a decade. In FY01 USAID invested

$12 million for the development and testing of microbicides and plans to raise this

to $15 million in 2002. One promising product to come from this process is the seaweed derived compound, Carraguard, that is currently receiving wide attention.

USAID is supporting field trials of this product in Africa.

TREATMENT, CARE AND SUPPORT ACTIVITIES

Care and treatment is important for humanitarian reasons. It also enhances prevention by increasing utilization of voluntary counseling and testing, and helping

to decrease stigmatization. It prolongs parenthood and economic productivity. By

treating the most important opportunistic infection, tuberculosis, we have prolonged

the lives of persons infected with HIV. We also help control the expanding TB epidemic, which threatens all countries.

People with HIV/AIDS have many needs in addition to health care. These include

psychological support, legal assistance, economic support, and accurate information

about HIV/AIDS. These are often as important as health care, since HIV infection

remains symptom free for many years. USAID has supported and will expand our

programs that provide non-medical services to people living with AIDS.

USAID produced ‘‘HIV/AIDS: A Guide for Nutrition, Care and Support’’ which

shows that, compared with the average adult, a person with HIV requires 10 to 15

percent more energy a day, and 50 to 100 percent more protein a day. We are now

incorporating food security activities into our care and support efforts.

Currently, we have 25 care and treatment projects in 14 countries. In Uganda,

USAID has begun a five-year, $31 million program to provide food to HIV/AIDS-affected families, to help reduce the impact of AIDS on households. We can help people survive longer by treating opportunistic infections such as tuberculosis and continuing to help countries build up their health care systems and infrastructure.

Antiretroviral therapy has had a dramatic impact in reducing AIDS mortality in

the developed world. However, there are a number of challenges that limit the ability to offer treatment and support to a large number of people. USAID is actively

trying to assess and solve these problems.

138

• The U.S. currently spends close to $4,000 per person per year on health care.

In many countries in sub-Saharan Africa, annual spending is about $40 per person—a 100 fold difference. Providing antiretroviral therapy to one person for a

year costs at least $600. Early on, approximately a quarter of those infected will

need treatment. This may seem a manageable number. However, since therapy

is lifelong, the numbers of people needing it will escalate, causing an ever increasing expenditure for treatment.

• Persons with HIV infection generally lack access to health care. There are few

health care workers trained to administer therapy, not enough laboratories capable of providing even the most basic tests to monitor patients for side effects,

and drug management systems that are too weak to prevent leakage of extremely valuable drugs into the black market.

• Without simple standard protocols for therapy and patient monitoring, it will

not be possible to provide therapy to large numbers of people in Africa. With

standard protocols, healthcare workers, under the supervision of a few physicians, can be trained to deliver therapy, adherence can be enhanced, and drug

management can be streamlined,

• Even with the most ambitious treatment plan, the demand for therapy will likely exceed the supply. National governments must address this issue. People living with HIV/AIDS must be actively engaged in this discussion.

USAID will be launching four antiretroviral (ARV) treatment sites in sub-Saharan

Africa this year. These sites will not only save lives but will also provide critically

needed answers to the challenges noted above and begin to build much needed local

capacity.

All of these efforts must build on a solid prevention strategy. We must closely link

treatment with prevention. Relying totally on treatment interventions will not stop

the advance of the pandemic. Lessons from the U.S., France, Brazil and other countries that offer ARV therapy clearly demonstrate that the introduction of combination therapy does not retard the epidemic. In fact, the belief that HIV is no longer

dangerous may result in increased transmission.

CHILDREN AFFECTED BY AIDS

More than 13 million children under age 15 have lost their mother or both parents due to AIDS. By 2010 some 44 million children in 34 countries will have lost

one or both parents, primarily due to AIDS. The impact of such large numbers of

orphans and other vulnerable children is substantial for the children themselves,

their families and the communities in which they live.

In sub-Saharan Africa, where the majority of AIDS orphans reside, gains in child

health achieved over recent decades are unraveling. In Zimbabwe, I worked with

street children orphaned by AIDS. I also taught AIDS prevention in schools where

the children’s greatest fear was that they too would lose their parents. Orphaned

children lose their families, their hope for education and the basic necessities of food

and shelter. They become easy prey for violence, sexual exploitation and crime. In

some settings, they are fodder for child militias.

While some communities have organized support for especially vulnerable children and households, many are weakened by the burden of illness and death as well

as the economic deterioration caused by AIDS. Helping communities care for their

own is a critical area where USAID can make a difference. We have models that

work and that can bring hope to families and communities.

This is the foundation of USAID’s support for children and families affected by

AIDS. Since 1999, USAID’s help for children affected by HIV/AIDS has increased

to more than 60 different projects in 22 countries. Supporting communities and families is the most efficient and effective way to address this tragic problem and reach

the millions who are and will be affected.

• In Namibia, community groups work together to keep orphaned and vulnerable

children in school.

• In South Africa, the Nelson Mandela Children’s Fund aims to reach an estimated 250,000 orphans and other vulnerable children through multisectoral initiatives in HIV/AIDS-affected communities.

• In Zambia, an interactive radio and local volunteer program helps out-of-school

and other vulnerable children continue to learn.

• In Uganda, research is underway to identify effective ways to support families

in planning for the care of children upon their parents’ death.

• In Rwanda, several programs work together toward the goal of providing food

to 22,000 AIDS-affected children.

139

I have seen that these programs can have impressive impact. In Zimbabwe, I met

with a local NGO that facilitated amazing community support to households headed

by teenage siblings.

WORKING TOGETHER MATTERS

No one agency can do it all. With so many new partners, the coordination of our

efforts becomes even more critical. This is as true among the U.S. government agencies as it is among our international partners, including the new Global Fund. Coordination efforts must occur at two levels: at headquarters and in the countries we

are assisting.

A good example is our work with CDC over the past two years. We have decided

upon a mutual list of priority countries, we have agreed upon strategic approaches

and we are finalizing new areas of specific expertise. We have signed a Memorandum of Understanding, which defines our collaborative efforts and establishes

on-going communication systems. Even more important is the coordination that

must take place within the country between CDC and ourselves and with the host

country government and community groups. It is there on the ground where we will

realize the impact of our combined resources.

An example of how we work together is seen in the area of surveillance. CDC has

taken the lead for the biologic surveillance of HIV prevalence while USAID is supporting behavior surveys. Together we use this information to track the epidemic,

target our resources and measure impact.

In the past two years, we have learned important lessons on what works and

what does not. We have successful models that are being replicated, and in six countries we are now seeing a reduction in new HIV infections at a national level. Drug

costs have come down dramatically and treatment protocols have been simplified.

We have the tools, we know they work. With your continued support and the new

resources you have given, we can now move ahead to save lives of millions.

Senator FEINGOLD. Thank you, Dr. Peterson, for your fine testimony, and I will begin with some questions for the panel and then

turn to Dr. Frist, and go back and forth.

Dr. McCray, you talked about the importance of adequate health

infrastructure for both prevention and treatment. Give me an idea

of what specific interventions the CDC is involved in laying the

groundwork for those components, and if you can tell the committee about a case in which all three components of the CDC effort are up and running, infrastructure, prevention, and treatment,

if you could give us an example of that.

Dr. MCCRAY. Yes. In a number of countries CDC has played a

major role in helping improve the public health laboratory infrastructure that is sorely needed to help support voluntary counseling and testing, which is a part of prevention, and help to support care and treatment, which requires some laboratory monitoring as well as help to support clinical followup with patients.

The example I would like to give is Botswana, where we have

been working with the Government of Botswana in implementing

the voluntary counseling and testing program. Those programs, we

have implemented programs in seven districts with an intent to go

to about 15 districts by the end of 2003. Those programs are directly linked to prevention of mother-to-child transmission, and are

being directly linked to care, and CDC is playing a major role in

implementing those programs in collaboration with the government, and have been very successful in doing that, so that is one

example of how we do it.

Senator FEINGOLD. Let me ask both of you, what kinds of innovative ideas have we developed to help address the challenges surrounding the cost and treatment protocols in resource-limited settings? In other words, what are some of the most promising treatments being considered today? Dr. Peterson.

140

Dr. PETERSON. There are a number of different elements. Certainly we have been working in our mother-to-child transmission

programs with the pharmaceutical companies, and they have been

providing the drugs for the programs as we work on the protocols,

and I guess again in South America one of the big things that

Brazil and the Ministry of Health partners told us is laying out negotiations with the pharmaceutical companies to decrease the

prices has been very instrumental in them coming down.

Overall, the partnerships, and I believe the corporate partners,

including the pharmaceutical industry, wants to be part of this.

They want to make a difference worldwide. They are actually contributing large amounts of drugs to the programs, and that is one

of the ways that we will make the most progress.

I do not know if it is innovative, but as you get all of the partners involved, the ministry of health, the communities that care,

the AIDS patients and victims themselves, working together with

our dollars, with the pharmaceutical companies, then you have a

nexus of people and dollar resources to really address this cost and

begin to make it possible.

The hardest is the public health infrastructure, to have the services far enough out, in all of the places to address the scope of need

that exists currently, let alone how big it could be if we do not get

a handle on slowing it down or stopping it.

Dr. MCCRAY. Actually, I was just going to give a concrete example of what is happening, what is beginning to happen in Uganda,

which is somewhat innovative in Uganda. USAID, CDC is beginning to work on two fronts, one in an urban setting and another

one in a rural setting, to implement ARV therapy in the urban setting of Kampala. The Academic Alliance, which is a private entity

that is primarily funded, I think, by Pfizer, we are going to be

working with them to help implement ARV comprehensive treatment programs in an urban setting, and the pharmaceutical, of

course, is providing a lot of the funds to support the facility that

will be used to evaluate and treat patients, was well as for providing free drugs.

We are working with other partners to secure antiretroviral—

CDC and USAID with other partners are also working in a rural

setting to implement a pilot ARV program that will actually use

minimal technology. In the urban setting we will have state-of-theart technology, viral load testing, CD–4 testing, et cetera, but in

the rural setting there will be limited resources, and we will use

minimal techniques that are being evaluated to monitor and follow

patients, and so those are all sort of innovative ways we are trying

to use to implement these programs.

Senator FEINGOLD. Thank you. In my opening statement and in

some of your comments we talked about cases where treatment and

prevention appear to complement and reinforce each other. I am

wondering if there are situations where this is not the case, and

if so, what factors cause the difference, for either of you.

Dr. PETERSON. I cannot give a specific case where having them

together would not have some synergy and complement. The biggest difficulty is, as Dr. Frist pointed out, the resources, and competing for resources, and balancing how much you put into the

treatment versus the prevention. It does make a difference.

141

The other place that we see that sort of synergy is when you

make the rapid testing available, and someone knows that when

they come in they are going to find out that day what their results

are, you get many more people coming in. We found the same

thing. If you know, when you come in and get your test, you are

actually going to be able to do something about it, it does encourage people to come in more, and it is just, how are we going to balance the resources, because we both want to treat and give compassionate care, we also want to stop the epidemic from spreading and

the next generation of youth within Africa not to become infected.

Dr. MCCRAY. I agree, and I really do not have a lot to add, except

to say I think one of the biggest challenges we are facing in the

countries is the fear by many of the national programs that once

they get engaged in care, moneys are going to be sucked away from

prevention, and they, in turn, see us as being competitive, and I

think part of our job is to help them understand that the two

should not be competitive in any way, and we need to develop models that clearly demonstrate that the two activities are complementary, so I think to the bottom line our biggest challenge is convincing national governments in many of these countries that it is

OK to get involved in care.

Senator FEINGOLD. Let me ask one more question before I turn

to Dr. Frist. Say a little more about the public health benefits that

can come from a solid voluntary counseling and testing program,

including spillover benefits that might not be AIDS-specific. For example, what effect do such programs have on other sexually transmitted diseases?

Dr. PETERSON. For a long time we would use rates of STD’s as

markers for our HIV prevention programs, because as you did your

counseling, your testing, your behavior change communication and

reaching out there, we did not early on have a way to know, we

did not have an HIV test that was reliable, and so we used rates

of STD’s, and so that is obviously the classic place that we see a

difference. Sometimes they follow teenage pregnancy rates. That is

not nearly as reliable, obviously, a way of following it.

The other is a much larger sort of social piece, and that is, as

you do the counseling and people can take ownership for their own

behaviors and risks, you take back some of the fear, pull them back

from the fear that I saw in the kids that I worked with, what is

happening to my family, what will happen to me and saying, you

do not need to just be afraid, some of this is under your control,

and give them back their future and a chance to plan where they

are going to go and what they want to do, that they can continue

in their education, and so all of those are opportunities that you

have as you do your counseling and testing to transform a culture.

Dr. MCCRAY. Just to add on the biomedical side, voluntary counseling and testing sites provide opportunities for you to get people

into specific care. In many of the centers we screen for syphilis as

part of voluntary counseling and testing when the blood is collected. In addition, in some of the centers we screen for active tuberculosis in patients who fit a certain syndrome that are referred

for screening and further followup to treat their tuberculosis. Those

who are found not to have tuberculosis in some countries they are

now beginning to use what we call INH preventive therapy to preVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00145 Fmt 6602 Sfmt 6602 77846.002 SFRELA2 PsN: SFRELA2
142

vent new cases of TB, so voluntary counseling and testing really is

an entry point to many prevention activities, as well as care and

many of the psychosocial support activities that are mentioned.

Senator FEINGOLD. Thank you very much. Senator Frist.

Senator FRIST. Thank you, Mr. Chairman, and I appreciate the

testimony of both of you, and your excellent written testimony as

well, and I really just have one question, and it has to do with, I

think, Dr. Peterson, I know in your written testimony you mention,

and that is the role of women and young women in what we can

do. I would like both of you to comment, because before going to

Africa this most recent time I did not have a full appreciation—I

probably just was not looking for it, but both the data that was presented in terms of the initiation of sexual activity, the importance

of education. Again, we talked a little bit about it at our hearing

yesterday, but I am increasingly fascinated by the education component, by the empowerment component.

I mentioned in my opening statement here that one of the more

impressive people, when with the Hewitts and others, I was with

in Africa, that we interviewed, the story of a woman who really became empowered culturally is a change in behavior, a change in

culture, but where she stood up really for her rights, when her husband died and everything normally would have gone to his family,

but just the more I look at this, as we are looking at places to incrementally have an impact both short-term and long-term.

It comes down to—an issue in this country we have, it is not addressed until, well, fairly recently, but the empowerment of women,

but these younger girls as we go forward. I am struggling with

what we do both from the CDC and USAID component, and what

we can do as a Foreign Relations Committee to both further emphasize that, institutionalize that, support that as we go forward.

I would be interested in both of your comments.

Dr. PETERSON. I think the situation really is remarkable. When

I was there I had similar kinds of stories, only we worked in rural

areas in Kenya. We would have women come to us and say, I know

my husband is coming back from the city and he has that disease,

and I do not have any way of saying no. How do I protect myself?

How do I not—I want to live to take care of my children, a heartrending kind of question, and early on, really what we could say

is, we will treat you for your STD’s, we will encourage you, but in

the last 10 years many huge things are happening.

There are starting to be policy guidance at national levels. There

are legal groups starting to give some legal rights to women to protect themselves in specific circumstances, and we do some of that

legal and policy support type of work. Education is key, working

with kids in schools. One of my favorite posters, that is actually the

only AIDS posters I have in my office, shows a typical sugar daddy

situation with a young schoolgirl, and when you show it in an African school setting they know exactly what this means, and the

question is, well, what can she do, and we would talk through, OK,

how could she not be in this situation, what could she do differently, and at first they think there are no solutions, but when

you work with them there are solutions.

But the biggest breakthrough for me was when we talked to the

boys and said, what would you think if this was your sister, your

143

cousin, how do you want to be part of the solution to some of these

situations that put the young girls, your girlfriend, your sisters, at

risk, and see the light go on in their eyes, that they have a role

and a responsibility within women’s issues and risks for HIV/AIDS

and other diseases as well, and so education is key.

On the biomedical side, one of the things that we have been researching and starting to do, obviously, is the female condom,

something that would put into women’s hands a way, a choice on

how to protect themselves. It has not taken off wildly, but we are

continuing to support research in those areas to give women a little

more choice about their own risks in places and situations where

they may not have other choices.

Dr. MCCRAY. I basically agree with most everything Dr. Peterson

just said. The only thing I would add is that one of the things we

are attempting to do is to support studies, especially behavioral

studies, to try to understand better some of the cultural and social

dynamics that affect women’s inability to prepare themselves and

then try to learn from the communities innovative ways that we

can then overcome some of these barriers, and USAID is also funding some of that kind of work, but I think we have to do a better

job working with local behavioral scientists, et cetera, trying to understand what many of the cultural and social factors are and

doing something to change those, because it has to be changed not

only at an individual level, but I think at a societal level as well.

Senator FRIST. Thank you, Mr. Chairman. Thank you both very

much.

Senator FEINGOLD. I will have a number of additional questions,

but so we can move on to the next panel let me ask just one more,

unless Dr. Frist decides he wants to ask more questions.

Dr. Peterson, you indicated USAID is implementing pilot treatment programs in a few of the African countries. Can you tell me

a little more about how the countries were selected? Are there

characteristics of each that will provide especially valuable information to the agency about how to pursue treatment in different

contexts? That is for either one of you.

Dr. PETERSON. We have the one in Ghana that we announced

today. The other three are still in negotiations, and it really depends on whether the Ministry of Health, as Dr. McCray pointed

out, are not all ready to move into this arena, that they are ready

and willing to work with us, that the infrastructure is there to actually do the first pilots, to have the people there to work with, and

that we can get the other logistical issues put together, so we have

actually talked to a number of different countries, and we have

three we are still negotiating with, and the other that is firmed up,

in addition to the ones that were ongoing with CDC, and they are

all places where there is significant threat and higher prevalence,

so they are areas of concern, but they need to have the infrastructure for us at least to begin to do the pilots.

Dr. MCCRAY. The three countries that we are beginning to have

these pilot projects in are Uganda, Kenya, and Botswana, where we

are working very closely with Harvard AIDS Institute, but the criteria differs a little bit for each country. In Uganda, it was clearly

a request that was made through the Ministry of Health. They

wanted us to help them look at ARV, or treatment, demonstrate

144

treatment projects in various areas. In Kenya, the initial request

for our involvement came through the Kenya Medical Research Association. It is the Kemri Medical Research Institute, which includes a group of leading infectious disease divisions.

They in turn met with the Ministry of Health staff and then basically got their buy-in, and then we are working with them to help

implement the ARV projects in Kenya, but the bottom line is that

they are usually the Ministry of Health—we feel it is important

that the Ministry of Health be on board and supportive of whatever

projects we plan to do in these countries, because our goal is to

demonstrate that it can be done, and the assumption is that there

will be a will by the government to then expand the programs to

make them available to others.

Senator FEINGOLD. Just a quick followup. For these pilot programs to be successful, what kind of resources are we talking about

that will be required to implement these on a larger scale, if you

could give me some sense?

Dr. PETERSON. To scale them up once we finished, or to do a

demonstration site?

Senator FEINGOLD. To do them on a larger scale.

Dr. PETERSON. I do not know if anyone has estimated how large

the cost would be. If you multiplied the number of people in Africa

who have HIV/AIDS and then look at how many of them, how

many are HIV positive, and then how many are AIDS and therefore susceptible to treatment, times the cost, and we did a rough

estimate yesterday, it ranges between $600 to $1,300 for drugs,

and so if the dollars keep going down, and it may be another $200

for health clinical costs, you multiply it out, and it is in a few billion dollars range. We are starting small to make sure we have got

the logistics right, and obviously the drug costs are continuing to

come down.

Dr. MCCRAY. I was just going to say, in Uganda they have been

really successful in getting the prices down to about $90 a month

just for the drugs, and with the additional cost for monitoring and

evaluation I would agree with the estimates that she has come up

with, but again, as part of these demonstration projects we are collecting information on cost so that at the end we will be able to

say, for the expected number of people living with HIV/AIDS who

will need to be on drugs, this is probably what it is going to cost

for you to try to implement this country-wide. That is one of our

goals.

Senator FEINGOLD. Thank you for your answers.

Senator FRIST. Can I just ask a followup, because I think that

question there is very helpful for me. Are the pharmaceutical companies participating, and on board, and specifically I am thinking

of the trials themselves in terms of these partnerships that I know,

Dr. McCray you were talking about earlier, and Dr. Peterson, because it is critical, and clearly they are down there. There is good

reason for them to be there, and some people are skeptical in terms

of why they are doing it, but just for us, for the trials—and again,

as I have been on the ground, you hear about these trials that are

coming. Is the partnership working with the pharmaceutical companies?

145

Dr. PETERSON. We have a long history of working with the pharmaceutical companies and getting free drugs in other disease areas.

They have been working very well with us and quietly been very

willing to provide selected drugs for us free or at lowest cost for

these projects, mother-to-child, and these new ARV’s, so I think

there is an ongoing relationship.

I think there is a hesitation about taking on the millions of people, and having to do it at less than their cost, and whether they

could actually sustain it, but they have been making an extra effort.

Dr. MCCRAY. CDC does not work directly with the pharmaceuticals, but we are working with the foundations that receive

support from the pharmaceuticals, and that is usually our entryway. An example is the PMTCT Plus program that is being supported by the Pediatrics AIDS Foundation as well as a number of

other foundations, and they are providing—we are collaborating

with them on a number of projects, and they will be providing the

drugs, but the pharmaceuticals are making those drugs available

almost free, or at very low cost.

Senator FEINGOLD. Thanks so much to both of you on this panel.

We appreciate it, and we will now move on to the second panel.

We also have an excellent second panel of witnesses with us

today. I would like to thank them for joining us. Let me introduce

each of them, and then I would ask each witness to testify in the

order of introduction. We will start with Dr. Jeffrey Sachs. Dr.

Sachs is the Galen L. Stone Professor of International Trade at

Harvard University, and the director of Harvard’s Center for International Development. His broad research interests have focused

on the links between health and development, along with economic

geography, globalization, and macroeconomic policies in developing

and developed countries.

He serves as economic advisor to the governments in Latin

America, Eastern Europe, the former Soviet Union, Asia, and Africa, and I am pleased to note that he was just appointed by U.N.

Secretary Kofi Annan to serve as Special Advisor on the U.N.’s Millennium Development Goals, and that position, Dr. Sachs will organize the United Nations’ research aimed at significantly decreasing

world poverty, disease, and death by 2015. Dr. Sachs has won

many awards and honors, and he is well-known to this committee,

and I am pleased to have him with us here today.

Dr. Jim Yong Kim. Dr. Kim is a trustee of Partners in Health,

the Harvard affiliated nonprofit organization that supports health

projects in poor communities of Latin America, Eastern Europe,

Asia, and the United States.

One of the leading world authorities on multidrug resistant tuberculosis, Dr. Kim serves as the director of the Program on Infectious Disease and Social Change at Harvard Medical School and is

an attending physician at the Brigham and Women’s Hospital in

Boston. Working closely with the World Health Organization, the

U.S. Centers for Disease Control and Prevention, and other stakeholders in the public nonprofit and commercial sectors, Dr. Kim

has played a central role in developing more effective global policies to control TB. In 1999, he coauthored the global impact of

146

drug-resistant tuberculosis, a groundbreaking report documenting

the epidemic rise of multidrug resistant TB worldwide.

Dr. Kim’s most recent book is, ‘‘Global Inequality and the Health

of the Poor,’’ an edited volume focusing on socioeconomic forces that

can undermine the ability to provide basic social and medical services to people in poor countries.

Mr. Martin Vorster is a very interesting witness from South Africa with us today. Mr. Vorster is a South African missionary who

has worked on AIDS prevention in a township outside of Pretoria,

South Africa, for the past 5 years. His religious ministry provides

in-home care for those suffering from AIDS, along with care for

AIDS orphans. They also provide assistance and care for those who

have been rejected or isolated by their families as a result of the

stigma that is so often attached to those who suffer from HIV/

AIDS.

We obviously welcome all of you. We are pleased to have all of

you here today. Dr. Sachs, if you would proceed with your testimony.

STATEMENT OF DR. JEFFREY SACHS, DIRECTOR, CENTER FOR

INTERNATIONAL DEVELOPMENT, HARVARD UNIVERSITY,

CAMBRIDGE, MA

Dr. SACHS. Thank you very much, Mr. Chairman. It is really a

pleasure and honor to be back with you and with this committee.

The two of you have led the way in the Senate and helping the

American people and your colleagues in Congress to understand

this issue, and I think we are seeing the fruits of your very hard

labors over the last few years.

This supertanker of ours is very gradually starting to turn in the

right direction, and I think you should take great pride in what you

are accomplishing in these years and in making better understood

this calamitous situation.

But I am here to say also that all is not right by any means, and

I think we still have not really turned the supertanker in the direction it needs to go, and I do not think it is a matter of just waiting

a bit longer and things will come out right. Millions of people are

dying as a result of the inaction of the United States and other

countries. Time is not on our side, both in epidemiological terms

and in terms of the real struggles of human beings that are dying

for neglect of modest resources.

I was mildly pleased by what I heard in the first panel, but I

have to say also I continue to be alarmed that we are now 65 million infections into this pandemic, and we have not put one person

on antiretroviral therapy yet, but we are starting, but we are 65

million people into this. USAID has not had one single person on

a donor-supported program on antiretroviral therapy, other than

the very beginning of the mother-to-child one or two dose, but in

terms of helping to keep the mothers and fathers, the doctors and

nurses, farmers, workers of Africa alive, the donor world has not

figured out yet to put one human being on treatment.

This is going to be one of the most puzzling and shocking features of our generation, when we look back, how we let it happen

again. The never again is happening again before our eyes, and I

do not really understand it, actually. Although I know all of the

147

real political explanations, I do not understand it or accept it. I

would hope that your leadership could help the U.S. Government

get better organized, because my basic message is, it is not organized yet.

I would ask four questions, first, who is in charge, second, where

is the strategy, third, where is the matching of resources and need,

and fourth, where are your colleagues in the Congress? I think we

need to figure out very fast answers to those questions. I think

there are good answers, but I do not think we have them yet. It

is just not good enough to have all the high rhetoric that we have

and end up with an fiscal year 2003 request of $200 million for the

Global Fund.

The only word that comes to mind is bizarre, and such a lack of

seriousness that one does not even know where to begin to understand what is happening at OMB or in the White House or in the

State Department or at HHS, or in the Treasury, or other places

where things might get done. There is no conception of linking

needs and actions. The rhetoric gets better and better, but at the

bottom line the one thing I know how to talk about in this, which

is the macroeconomics, we are just nowhere right now, and it is

just impossible to understand, frankly.

In a budget proposal where $62 billion of tax decreases are budgeted and apparently are not going to be done because we are not

going to have a stimulus package we hear the political leadership

of the United States say there is no more money than $200 million.

It is just not so. We are a $10 trillion economy. We are a $2.1 trillion budget. We have billions and billions of dollars built in, $224

billion built in for the military increases. We have more than $200

billion built in for a stimulus. We have $141 billion built in for a

stimulus package which is not even going to take place, and then

we are told $200 million is what we can come up with.

We hear our Secretary of Health and Human Services say that

we just do not have more money. I do not know what that means.

What I think it means is we have not done the serious work of saying what can be accomplished with the money, what happens with

scaling up, how much would it cost, what is a timetable, what is

a multiyear strategy, how do the pieces fit together?

We heard an extraordinary answer just now to your question

both to CDC and to USAID. It is not acceptable, in my opinion, in

the 21st year of this pandemic, that they could not give an answer

of the cost of scaling up. That makes no sense for us, as the greatest country in the world, that we have not been able to get organized to give an answer to that question. It is not so hard to do.

The right answer, by the way, is that roughly, it is $1,000 per person per year for treatment, all costs included, drugs and all of the

ancillary testing, counseling, medical care.

Probably that is in my view the outer limit. I saw cases a couple

of weeks ago when we had the great pleasure to meet Senator Frist

in Kampala. Just before that I was in Malawi, where the drugs

were $1 a day, $350 a year from Cipla, and the extra costs were

probably about $200 per patient, I would say under $600 per year

to get the job done with a regimen which we were told was working

extremely well.

148

But let me paint a picture for you, if I could, just very briefly.

In one ward of a hospital I saw a sight which I hope never to see

again, of course, but at the same time I wish every one of your colleagues could see. The ward had hundreds of people in it, three to

a bed. It is something unbelievable. There were no drugs in the

ward. Everyone was dying. So you look into a room where there is

just death going on, two in a bed, one under the bed.

Across the hall was the outpatient clinic where, if people could

afford $1 a day, they were getting treated. They were walking out

of the clinic because these drugs are incredibly effective, and they

are not so impossible to deliver as one of the great practitioners of

this is about to tell you, because this man is an inspiration, and

his partner. They prove the concept just by doing it, but now I have

seen all over Africa it is just being done if you can afford the $1

a day.

So in one room thousands are dying each month, the other room

a few hundred are surviving because they can afford it. There is

nothing lacking but the resources. In that case, Senators, there is

nothing lacking but the few bucks that it would cost, and we have

so far made a calculation that Africans are not worth $1 a day to

keep alive. That is the calculation the rich world has made, and

they agonize over this.

Are Africans really worth $1 a day to keep alive? Are Africans

cost-effective at $1 a day? Is it cost-effective to have 40 million orphans? Is it cost-effective to have a continent fulminant in disease?

Is it cost-effective to have millions going hungry because the farmers are dead? Is that what we mean by cost-effective? Is it cost-effective for us to be allowing a generation to die for lack of a few

dollars per American?

Well, our government has not even done the calculations, Senators. I know that. I spent 2 years as chairman of the Commission

on Macroeconomics and Health for the World Health Organization.

We did the calculations, and I hope that everyone on the committee

has gotten the text. I think it is pretty authoritative. I can say that

because I did not make the calculations, but the London School of

Hygiene did, and experts from all over the world, and we found

that for a penny out of every $10 in the rich world, one penny out

of every $10 of income in the rich world we could save 8 million

lives per year. That is the kind of calculation that the world that

we are really living in.

If the rich countries each raised $1 per person, Senators, that

would be $1 billion per year. That would save a million lives at

least each year, $1. That is the kind of calculation we need to be

making. Our government is absolutely winging it. That I believe is

unacceptable in the greatest pandemic in history, that they cannot

give you a 5-year strategy, a scaling up cost estimates, and I know

they cannot because they do not do them. No one is in charge. No

one is making a strategy. They are winging it.

They tested the air. They said, we will give $200 million. Then—

it is bizarre. They said, $500 million, but you know, that is a weird

way to say it. I am sorry. People need the drugs each year. You

do not keep adding the pile. It is $300 million this year, then $200

million next year. What kind of strategy is that?

149

My God, thank goodness we do not fight wars that way. You

know, we do not just wing it, and that is what we are doing, and

so our basic message—and I have given you detailed testimony, but

my basic message is, we have got to stop winging it. It is a game

right now. It is a game of the minimum amount that can be gotten

away with. To say we are doing it, we have got a site here, we have

got a site there, there is no strategy right now. There is no scaling

up strategy where 40 million people are affected now, 20 million

have died, and they cannot give you a straight answer of what the

cost of scaling up would be because they have not thought about

it even.

[The prepared statement of Dr. Sachs follows:]

PREPARED STATEMENT OF PROF. JEFFREY D. SACHS, CHAIRMAN, WHO COMMISSION

ON MACROECONOMICS AND HEALTH, DIRECTOR, CENTER FOR INTERNATIONAL DEVELOPMENT, HARVARD UNIVERSITY

Senators, thank you for the opportunity to testify today regarding one of the most

urgent problems facing humanity—the global AIDS pandemic. The decisions that

the Congress and Administration make regarding the pandemic will determine the

life or death of millions of people in the next few years, and will affect America’s

security and standing in the world for decades to come. To date, the United States

and other donor countries have under-financed AIDS control in poor countries. This

has allowed the pandemic to run rampant. Millions of poor people are needlessly

dying every year when their lives could be extended by appropriate medical care at

modest cost and enormous benefit to the

Last month, I visited some of the dying fields of Africa. I stood in Queen Elizabeth

Hospital in Blantyre, Malawi where 70 percent of the medical admissions are AIDSrelated. Hundreds of patients are crowded into the wards to die, two or three to a

bed, with patients also lying on the floor under the beds. Hospital services are collapsing under the weight of the epidemic. There are no life-saving drugs given to

these people because neither the dying patients nor the Government of Malawi can

afford the medications.

Yet across the hall, an outpatient service successfully treats the small fraction of

HIV-infected people who can afford one dollar per day. Hundreds of people are successfully on antiretroviral therapy. The problem in this hospital is not infrastructure, doctors, testing equipment, adherence by patients, the ability to tell time—it

is simply the shortage of $1 per day per patient that would supply life-saving drugs.

Even when one adds in the testing and counseling costs in addition to the direct

costs of drugs, it is very likely that total spending would remain well under $3 per

person per day.

While the stain of U.S. neglect during the first 20 years of the pandemic can

never be washed away, it is not too late to act, for our direct security needs as well

as our moral purpose as a great nation. The United States should increase its

spending on AIDS control by contributing at least $2.5 billion in FY03 to control

of AIDS in poor countries, of which at least $2 billion should go the Global Fund

to Fight AIDS, tuberculosis, and Malaria, for the reasons described below. Our contribution of $2.5 billion to AIDS control should be matched by at least $5 billion

from Europe and Japan, for a total outlay of $7.5 billion for HIV/AIDS control. The

Global Fund should disburse at least $6 billion for AIDS, tuberculosis, and malaria

in FY03.

The Global Fund has $700 million for disbursements in 2002, of which the U.S.

share is $250 million. The Congress and the Administration should agree to a supplemental appropriation of at least $750 million for FY02, to raise the U.S. contribution this year to $1 billion. This in turn should be matched by at least $2 billion

from Europe and Japan, for a total of $3 billion. Without this supplemental appropriation, the Fund will either run out of money during the year, or will drastically

ration the size of programs that it approves, to the serious detriment of disease control efforts.

150

1Table 1 appears at end of statement.

2 Chart 1 appears at end of statement.

SCALE OF FINANCIAL ASSISTANCE FOR HIV/AIDS CONTROL IN POOR COUNTRIES

Table 1 1 breaks down the financing of AIDS control in recent years, and estimates the needs for U.S. contributions for AIDS and for total disease control efforts

in poor countries in the coming years. In the second half of the 1990s, America spent around $10 billion dollars per year battling the AIDS epidemic at home, but only around $55 million per year in helping Sub-Saharan Africa. It is worth recalling that the U.S. has about 1 million HIVinfected individuals, while the developing world has 38 million infected individuals.

Treatment costs, I will note below, are of course much lower in the poor countries,

but the combination of prevention and treatment costs will still require vastly higher donor assistance to meet the needs of the tens of millions of individuals already

infected and the hundreds of millions that are at risk of infection.

U.S. international assistance to fight AIDS has recently begun to increase, to around $680 million in FY02, with perhaps two-thirds of that aimed at Africa (depending, for example, on allocations from the new Global Fund to Fight AIDS, TB,

and Malaria). The FY03 budget request again increases the total international

spending on HIV/AIDS to around $844 million, with $200 million requested for the

Global Fund. While these recent spending increases are certainly in the right direction, U.S. assistance is still woefully short of any realistic sum needed to help the

poorest countries, especially in Sub-Saharan Africa, fight the AIDS pandemic. Secretary General Kofi Annan has called for $7 to $10 billion per year for the control of AIDS in low-income countries, an estimate that has been supported by several expert studies, published in the world’s leading journals, such as Science Magazine (Schwartlander, et. al., 2000) and elsewhere. Looking out a few years, the

worldwide need for donor assistance to control AIDS will probably be at the high

end, perhaps reaching $10-15 billion depending on the course of the epidemic, the

evolution of treatment costs, and ability of the low-income countries to scale up

AIDS control efforts.

In the past two years, I chaired the WHO Commission on Macroeconomics and

Health, which was charged in part with determining donor financing needs to address the interlocking pandemics of AIDS, malaria, tuberculosis, and other killer

diseases. Our study, released in December 2001, determined that Sub-Saharan Africa would need total donor assistance for health of around $18 billion per year as

of 2007, of which more than half would be devoted to the control of AIDS, with the

rest directed at other killer diseases such as tuberculosis, malaria, vaccine-preventable diseases, respiratory infections, and diarrheal diseases. Since other regions

would also need donor assistance to fight AIDS, the worldwide need for donor assistance to fight AIDS could reach $10-15 billion per year by 2007.

Since the U.S. represents around 40 percent of the GNP of the donor world ($10

billion out of $25 billion in total donor GNP), the U.S. share of the total health assistance will need to be at least one quarter of the total, if not more. This means

that U.S. spending on AIDS in Africa will require at least $2 billion per year, and

total U.S. foreign assistance for AIDS should reach at least $2.5 to $3 billion per

year worldwide in FY03. According to the Report of the Commission, total worldwide

donor spending on all types of health programs should be approximately $27 billion

per year by 2007, so that total U.S. health assistance would be in the range of $7-

$8 billion per year, roughly five to six times the current level.

These numbers may seem large, Senators, but the amount of suffering and global

risk posed by the pandemic diseases is far greater. The Commission findings suggest

that if the U.S. invests on the order of $7-$8 billion per year as part of a global

program of around $27 billion per year as of FY07, around 8 million deaths will be

averted each year by the end of the decade. We can save 25,000 people every day

from deaths due to AIDS, malaria, tuberculosis, and other killers if we put our

minds, and a modest part of our incomes, to it. Note that $7 to $8 billion per year

for global health needs would represent far less than one half of one percent of our

national budget, and less than one penny out of every 10 dollars of our income.

The United States, while the second largest donor in absolute terms (after Japan),

has become the smallest donor in the world when aid is measured as a share of income! (Chart 1) 2. We are now spending only 0.1 percent of GNP on all forms of official development assistance, compared with an average of more than 0.3 percent of

GNP in Europe. The oft-repeated excuse that ‘‘aid does not work’’ is a cruel abnegation of U.S. responsibility. We must stop talking about ‘‘aid’’ in generic terms, and

start discussing targeted financial support for specific health interventions—such as

prevention and treatment of AIDS, increased coverage of immunizations, wider disVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00154 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
151

semination of antimalaria bednets, and the like. History demonstrates that such

targeted interventions have a high success rate. From the expanded program on immunization (EPI); to the campaigns against smallpox, polio, African river blindness,

and trauchoma; to the spread of oral rehydration therapy; directly observed therapy

short-course (DOTS) for tuberculosis, and insecticide-impregnated bednets, foreign

assistance for health has worked well. Unfortunately, the level of aid has always

been tragically meager compared with the level of need.

DONOR SUPPORT FOR ANTI-RETROVIRAL THERAPY IN POOR COUNTRIES

Life-saving antiretroviral combination therapies have been available since the

mid-1990s. Yet given the low levels of donor assistance, the stunning fact is that

not one person in the developing world—out of the more than 60 million who have

been infected by the HIV virus since 1981—has received such drugs through official

donor support from the U.S. or any other country or multilateral institution. Let me

repeat that, Senators. Not one person in the developing world has yet received

donor-supported antiretroviral therapy! The U.S. and other leading donors have so

far turned their backs on millions of dying people. This dreadful fact is supposed

to change, finally this year, when the Global Fund and USAID both begin to support

the introduction of antiretroviral therapy. Yet the donor sums so far committed in

2002 will permit only a very small scaling up of treatment relative to the enormous

needs.

For many years it was casually supposed that antiretroviral treatment was too

expensive for low-income countries. Drug regimens cost $10,000 or more per year

in the United States. But it has come to be understood that the prices of

antiretrovirals in the $300-$750 dollars per regimen per year, depending on the precise combination of medicines. The high margin of the price over marginal production cost reflects the returns on research and development, a margin that is properly

protected by patent rights. Yet, the lower production costs make it possible to provide the low-income world with the drugs at the actual marginal cost of production,

close to $1 per day for the least expensive combinations. The leading pharmaceutical

companies, and high-quality generic producers that have access to the African market (which has little patent coverage for most of the relevant drugs) have shown

their readiness to provide drugs at the much reduced prices. Still, the impoverished

countries in Africa require donor assistance even to cover the costs of $1 per day

for the drugs (and perhaps another $1 per day on average for the accompanying

testing and medical care).

A high-end estimate is that anti-retroviral treatment will require around $1,000

per patient per year in low-income settings, including the costs of drugs, testing,

and medical care. This can probably be reduced to around $500 per patient per year

with further reductions in drug prices, and optimized regimens regarding testing

and medical care. Of the 25 million Africans currently infected with HIV, perhaps

4 to 5 million would qualify for highly active antiretroviral therapy on clinical

grounds. Of these, it is estimated that perhaps 25,000-50,000 are currently receiving

the medicines, while the rest are dying. Even those receiving the medicines are

often on sub-optimal regimens, with interruptions of drug availability, inadequate

drug combinations, and poor monitoring.

UNAIDS, WHO, and other expert groups that have looked closely at this believe

that 5 million people in low-income settings, mainly in Africa, could be on successful

antiretroviral therapy within 5 years. Indeed, the numbers could be even higher is

scaling up is given adequate support. That would suggest a total cost of around $5

billion per year for antiretroviral treatment by FY07, plus the costs of prevention

programs and treatment for opportunistic infections, thereby arriving at the cost estimate of $9-$12 billion of donor support by FY07.

THE GLOBAL AIDS PANDEMIC AND U.S. SECURITY

Let me briefly address the highly adverse foreign policy implications of the AIDS

epidemic for the United States, and then discuss the importance of scaling up treatment, including anti-retroviral therapy, to control the epidemic.

AIDS is destroying the prospects for African economic development and democracy

The greatest hope for democracy and economic progress in Africa remain our

friends such as South Africa, Nigeria, Botswana, Ghana, Mozambique, Malawi, and

Tanzania. These nations, among many others in the region, are being ravaged by

AIDS. Foreign investment has been seriously impeded as investors avoid countries

where a significant proportion of the labor force is likely to be HIV-infected. The

labor force, including the most highly productive age groups, is being wiped out.

Sub-Saharan Africa now has 25 million HIV-infected individuals, roughly 9 percent

152

of the adult population between the ages 15 and 44. More than two million Africans

are dying of AIDS each year. In Southern and Eastern Africa, the prevalence is well

above 10 percent, and in hard hit countries, 25 percent or more. AIDS has become

a dire and fundamental impediment to economic progress in Africa and leaves an

even more troubling legacy: tens of millions of orphaned children.

AIDS is creating a demographic catastrophe, with profound security risks

AIDS has already left behind more than 12 million orphans, and epidemiological

estimates suggest that the number could rise to 40 million by the end of the decade

unless the pandemic is staunched. As America lets millions of Africans die for want

of $1 per day in medicines, millions more children are left orphaned. Common sense

and repeated studies have shown that these children are at great risk of hunger,

neglect, withdrawal from schooling, crime and violence.

AIDS is creating a breeding ground for terrorism

Disease is repeatedly found to be one of the most powerful predictors of state collapse and internal violence. The CIA Task Force on State Failure identifies high infant mortality rates as one of the three most powerful predictors of subsequent state

failure (in addition to lack of democracy and lack of open economy). Furthermore,

AIDS is decimating adult populations and increasing the percentage of populations

which are aged between 15 and 24. Research has determined that such demographic

shifts are a major predictor for the outbreak of conflict.

AIDS is fomenting a social and political backlash against the United States

Throughout Africa and the developing world, people believe that they have been

left to die by America. They are aware that life-saving drugs exist to save them,

but that those drugs are not being made available. Conspiracy theories abound in

Africa that AIDS is a deliberate policy of genocide by the United States, or an accident of the CIA gone awry. These desperate flights of fancy aside, our actions to

date point to one conclusion: America judges African lives to be worth less than $1

or $2 per day.

AIDS is threatening China and India and other parts of the world

What has come to Africa will soon be true in the populous centers of Asia, including India and China, where the epidemic is still in its early stages. The destabilization that could arise from full-fledged epidemics in those countries is harrowing. We

must not ignore the central truth about epidemics: they are far less costly to control

at an early stage.

AIDS originated in Africa, probably West Africa, sometime around 1930 according

to the best current estimates. It went undetected for decades, in part because of the

remarkably poor state of public health surveillance in Africa, and was only identified as a new disease in 1981 after it had spread to the United States. In this sense,

AIDS is precisely the kind of threat of cross-border transmission of infectious diseases that public health officials have warned us about for decades. Our neglect of

burgeoning infections abroad—whether from AIDS, or tuberculosis, or other new

and rapidly evolving viral and bacterial conditions—poses stark risks to American

public health. The day has already arrived when any one of us could, during a flight

or in a theater, be infected with multi-drug resistant tuberculosis, the treatment of

which involves two years of chemotherapy. AIDS is also evolving rapidly, and there

are reasons to suspect that some viral subtypes may be more transmissible and virulent than others. New forms of the disease in Africa or elsewhere, especially if uncontrolled, will readily jump to the United States with dire consequences. Thus, we

must act decisively not only because it will save lives abroad; it will save lives here

at home as well.

DESIGNING A CONTROL STRATEGY THAT CAN MEET THE CHALLENGE OF A GLOBAL

PANDEMIC

AIDS requires a comprehensive strategy, including both prevention and treatment

The most pernicious myth of donor policy has been that prevention alone, without

treatment, will control the epidemic. This view is brutally shortsighted and fundamentally flawed. Both prevention and treatment are necessary. In the Report of

the Commission on Macroeconomics and Health, we concluded that total spending

on AIDS should fall into three roughly equal categories: prevention programs; treatment of opportunistic infections; and antiretroviral therapy.

Anti-retroviral therapy is necessary for two basic reasons. First, we cannot afford

to allow millions of working-age Africans—mothers and fathers and core members

of the labor force—to die for lack of $1-$2 per day in medicines and treatment costs,

given the enormous resulting losses in economic development, the millions of orVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00156 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
153

phans that would be left behind, and the resulting threats of violence, political destabilization, and social upheaval. It is just dreadful economic miscalculation to believe that it is ‘‘cost effective’’ to stand by and allow a generation to die for lack of $500-$1000 per patient per year for medicines and ancillary care.

Second, treatment is vital for successful prevention. In the United States, the

Centers for Disease Control terms antiretroviral treatment a form of ‘‘secondary prevention.’’ The availability of treatment encourages people to get tested for HIV infection, and then to receive counseling if they are infected. Yet in Africa, where testing

is not now followed by treatment, individuals rarely seek testing and counseling.

The benefits of treatment for prevention go well beyond encouraging counseling

and testing. Stigma is reduced when the disease is known to be treatable, and the

disease can be addressed in much more direct and sensible manner. Irrational and

often highly destructive social interpretations of the disease (e.g. that it is a form

of witchcraft, or a CIA form of bioterrorism, or that it can be cured by having sex

with a virgin) are diminished as soon as successful medical interventions are demonstrated. Politicians stop hiding from the epidemic when they can offer hope to

their populations. Medical staffs, currently unable to save their dying patients for

want of medicines, are re-energized to fight the epidemic.

Treatment is feasible at a greatly enlarged scale

Physicians experienced in Africa know that treatment can be successfully scaled

up dramatically. Many doctors in Africa and other resource-poor settings are already successfully treating patients, but only the small proportion who are able to

purchase the drugs out of pocket. With concerted financial support, training to African medical personnel could be expanded dramatically; testing facilities could be expanded or created; and new protocols could be elaborated to ensure a reliable flow

of drugs and high patient adherence to drug regimens. WHO and UNAIDS estimate

that at least 5 million patients in low-income settings could be on anti-retroviral

therapy by the end of 2006.

The Global Fund is the best single investment for the United States in AIDS control

The Global Fund to Fight AIDS, Tuberculosis, and Malaria is an important new

weapon in the fight against AIDS. The Fund was formally launched in January

2002, and will receive the first round of proposals by March 10, 2002. Initial funding

is likely to begin by late April.

The Global Fund has several key strengths.

(1) The Fund will be the key source of multilateral grant financing for AIDS

control in low-income countries, especially since the World Bank is still hamstrung in making loans rather than grants for AIDS control efforts in low-income countries;

(2) The Fund effectively pools donor resources, so that countries can create

a comprehensive strategy and apply to one single source of financing, rather

than to twenty or more distinctive and often contradictory assistance programs

supported by individual bilateral donors;

(3) The Fund leverages U.S. funding by encouraging donor support from Europe, Japan, and other high-income countries. The initial U.S. contribution of

$250 million for FY02 has now been matched by at least $1.5 billion from other

donors.

(4) The Fund offers Congress and the international community a transparent

mechanism for monitoring the flow of funding proposals and funding decisions,

thereby helping to ensure that donor funds are disbursed in a sensible and evidence-based manner. One of the strongest features of the Global Fund is that

proposals will be vetted by an independent expert review committee;

(5) The Fund is already spurring initiative at the grass roots (including local

nongovernmental organizations), as well as increased collaboration between governments and civil society;

(6) The Fund will enable selectivity in the choice of programs and countries

that will be funded, so that funds can be held back from corrupt governments

and inappropriate programs;

(7) The Fund will enable improved monitoring and auditing of the actual use

of donor funds.

The Research Effort to Find a Vaccine and Improved Medicines Should be Intensified

The U.S., through the National Institutes of Health, is already the world’s leader

in basic research in AIDS. This leadership should be maintained and enhanced,

with increased research contributions from other donors as well. Recent advances

in vaccine research suggest that an effective vaccine may be available within a decVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00157 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
154

ade, if not sooner. There will need to be considerable coordination across countries

in the basic research, product development, and clinical testing, to speed the process. The International AIDS Vaccine Initiative, among others, has already made important strides in this area, and work by IAVI and others should be supported by

the U.S. Government.

IMMEDIATE STEPS

Budgetaty outlays of $2.5 billion FY03

The Congress and Administration should support a U.S. contribution to AIDS control of at least $2.5 billion in FY03, of which the Global Fund should receive at least

$2 billion, compared with the Administration’s request of $200 million.

Supplemental budget in FY02

Congress and the Administration should be prepared to make a supplemental appropriation for the Fund during FY02 of $750 million, raising the FY02 U.S. contribution to $1 billion.

Bi-partisan Congressional Mission to Africa during this Spring

Given the urgency of the global AIDS pandemic, and the role that the U.S. must

play to overcome it, it is critical for Congressional leaders and staff to understand

the crisis on a first-hand basis. Much of what is reported, especially the alleged obstacles of effective treatment in the African context, does not reflect on-the-ground

reality. Moreover, the sheer scale of the crisis is difficult to fathom without a firsthand view.

For this reason, I strongly urge that the Congressional leadership appoint a bipartisan mission to travel to Africa and to report back to the Congress this Spring. The

claims and counter-claims can then be evaluated directly, and the shocking enormity of the crisis will better be brought to the American people through their Representatives in Congress.

The Opportunity

The United States has missed an enormous opportunity during the past two decades to establish global leadership in quelling the AIDS epidemic. It’s been an opportunity to not only save lives and make a contribution to the global economy; it’s

been an opportunity to promote enormous good will towards our nation, to shore up

democracy and economic growth, and to lessen the threats posed by destabilized

states.

I come today bearing one message: today is not too late to act. While millions have

died and instability has grown, we can still avert the worst. Senators, in our lifetimes our children and grandchildren will ask us what our country did during the

worst epidemic to strike humankind. With your leadership, I hope that we shall be

able to offer a response that makes us all proud to be Americans.

155

TABLE 1.—Estimated Budgetary Outlays and Needs for AIDS and All Disease Control

FY1995-1999 FY2000 FY2001 FY2002 FY2003 Estimated Need by FY2007

U.S. AIDS Spending Domestically ............................................... $10 billion $10 billion $10 billion $11 billion $12 billion ....................................U.S. AIDS Spending in Poor Countries ........................................ $120 million $235 million $449 million $680 million $844 million ....................................U.S. AIDS Spending in Africa ...................................................... $55 million $109 million (USAID)

+$25 m (est. CDC)

$145 million (USAID)

+$75 m (est. CDC)

$450 million (est.) $525 million (est.) ....................................

Estimated AIDS Needs from all Donors ...................................... .................................... .................................... .................................... .................................... $7-10 billion $9-12 billionEstimated AIDS Needs from U.S. ................................................ .................................... .................................... .................................... .................................... $2.5 billion $3.5 billionU.S. Funding for all disease Control .......................................... .................................... .................................... .................................... .................................... $1 billion (USAID)

+$350 m (est. other)

....................................

Estimated Needs for U.S. funding for all Disease Control ........ .................................... .................................... .................................... .................................... $3-4 billion $7-8 billionU.S. Contribution to Global Fund ................................................ .................................... .................................... .................................... $250 million $200 million ....................................Estimated Need for U.S. Global Fund Contribution .................... .................................... .................................... .................................... $1 billion $2 billion $3 billion

156

157

Senator FEINGOLD. Doctor, let me just say that that is some of

the most powerful and passionate and important testimony I have

ever heard on this subject. I will not soon forget it. I would agree

158

with you that this amount that the United States is putting forward is not adequate, and that when the Secretary-General talks

about $7 billion to $10 billion, yes, that figure is an annual figure,

and this idea of counting up everything, as you just pointed out,

and saying we have done $500 million really is a confusing way,

and a rather handy way to point out an amount of contribution

that does not do the job, so thank you for that.

We are coming to another bind with votes and so on, so I am

going to move on to Dr. Kim. The vote may start shortly, and I may

have to recess us again for a while, but we will return to hear the

other testimony and to have some questions.

STATEMENT OF DR. JIM YONG KIM, DIRECTOR, PROGRAM IN

INFECTIOUS DISEASE AND SOCIAL CHANGE, HARVARD MEDICAL SCHOOL, BOSTON, MA

Dr. KIM. Thank you for inviting me. The introduction painted me

as a multidrug-resistant TB person, but we also run a project in

Haiti in which we are providing antiretroviral therapies in Central

Haiti, one of if not the poorest region in the entire Western Hemisphere, and what I want to talk to you about is several things, but

much of it has been covered. I was asked to talk about the synergy

of prevention treatment the notion of antiviral drug-resistance and

what we mean by infrastructure.

I will reflect on those issues, but in terms of my own personal

experience over the last 15 years trying to deal with not only AIDS

and tuberculosis, but many of the other afflictions that devastate

the poor. I am a physician, but I am also an anthropologist. I did

the two degrees together, and I am also an infectious disease and

internal medicine physician working in a hospital. We do all these

things at Harvard University, but our real work is in developing

countries.

We work in the Central Plateau of Haiti, and we work in the

slums of Lima, primarily Lima, Peru, but also more recently been

working in the prisons of Siberia and also in the inner city of Boston, and I think one message that I will start with is that we are

really in a different time now.

This is the time of AIDS. How we respond to this epidemic will

define certainly my generation of physicians, but it will define us

all as human beings. The traditional approach to public health has

been extraordinarily effective for what it was designed to do. We

felt that the most we could do in developing countries was take a

small amount of money and divide it up as efficiently and as effectively as possible. We are no longer living in that age. We need new

paradigms in public health.

Dr. David Heyman, who is the head of the communicable diseases cluster at the WHO, recently said just that, a populationbased approach which tries to, quote-unquote, ‘‘Keep It Simple stupid (KISS),’’ the classic KISS approach to public health, is no

longer adequate. We, in working in the slums of Lima, stumbled

upon an epidemic of multidrug resistant tuberculosis [MDR–TB].

This is a form of tuberculosis that is resistant to the two most powerful antituberculosis drugs. Once you reach the stage of MDR-TB,

the traditional approach does not work any more. You have to use

old, second-line drugs, that are second-line drugs because no one

159

uses them any more. There have been no new drugs for tuberculosis in the last 30 years. Despite the fact that it used to be the

No. 1 killer among infectious disease of adults. We use these drugs

over a period of 2 years. They have very toxic side-effects. We have

to manage the side-effects very aggressively. We did it using community health workers, student nurses, and we trained some of the

local doctors. Right now, the entire program is being run by local

physicians, and we received a grant from the Bill and Melinda

Gates Foundation of $45 million to do precisely what you asked

about today, which is scale up a very complicated invention to an

entire nation.

We have had to quintuple the number of patients on treatment,

and we have had to train health workers, nurses and physicians

to manage very complicated treatment regimens and to deal with

the side effects. We do directly observed therapy every day for 2

years. This is clearly the most complicated intervention that has

been undertaken on a national scale anywhere in the world that

we know of. Compared to MDR-TB therapy antihigh retroviral

therapy is easy. It is harder to sustain, because we have to do it

over a much longer period of time.

In Haiti in 1998 through drug donations we started treating our

most ill patients with the triple combination antiretroviral drugs.

The way we did it was, we did directly observed therapy for one

of the two doses every day. In the morning, the community health

worker goes and gives the patient their morning dose. Right now,

the combination we are using is one pill in the morning, and four

pills in the evening. It is a twice-a-day regimen, and then the family members supervise the evening doses.

Every single patient has had a positive outcome. We did not have

access to CD4 testing when we started, so we did it based on

syndromic management, something Drs. Peterson and McCray

talked about a little bit earlier. The results so far, and we have not

even published it yet, but Dr. Bruce Walker of the Harvard AIDS

Institute graciously has been doing some testing for us for free, of

the first 50 patients we have tested we have 84 percent full file

suppression. There is some resistance, but it is trivial. The resistance that has developed will not limit our ability to treat any of

the remaining patients. All have had weight gain. We have only

had to change regimens on a few of the patients.

My colleague, Paul Farmer, who is our primary person in Haiti,

tells me that we cannot—we cannot extrapolate our experiences in

the United States to places like Haiti. He says, the great irony of

my life is that in the United States I beg my patients to take their

pills, but in Haiti, the patients beg me to give them pills. It is a

different phenomenon, doing this in the developing world, where

people at every socioeconomic level are infected and affected.

Let me go on to the question of infrastructure. Often we hear

talk about infrastructure as if it were love or goodwill, something

to decry the lack of, but because we do not really know exactly

what it means, we do not have to define it. Well, we have looked

and we have built our programs on the back of very minimal infrastructure.

In Peru, the DOT’s, the local DOT’s basic TB control program, we

had to train some new people. We had to train specific physicians

160

in the management of MDR-TB, but this was quite frankly not

rocket science in Haiti. The expansion of our TB program to what

we call our DOT, our directly observed antiretroviral program, was

a matter of taking our TB workers and giving them 2 full days of

training on the management of antiretrovirals. We are still able to

do that now. We have not yet received money to scale up in Haiti,

but we are very hopeful that we will receive funding for that soon.

Infrastructure exists in so many different forms. Often also we

hear Africa spoken about as if it were a country. There are enormous differences across Africa, and our organization did a little

study where we sent an e-mail out to organizations that are concerning themselves with HIV. We found 38 that are effectively involved in treating patients. We also have had requests through

Professor Sachs from corporations, from churches, from communitybased groups for help in translating some of our tools and our

methods to other places in Africa.

Infrastructure exists in so many different forms, for example,

companies are ready to treat the pharmaceutical industry as setup

programs you have already heard about that provide a very nice

infrastructure, community based organizations, there are publicprivate partnerships, tuberculosis and immunizations programs, all

of these are ready to scale up. We simply need the resources to do

so.

As I said, this epidemic will define our generation. To reflect a

little bit on the notion of the Black Plague, what is happening right

now is that we have therapy that we can provide, and we are not

providing it. This is not like the Black Plague. We do not have answers. This is not going to be easy. We need to start immediately,

though, to figure out in each place, in each local area how to implement these programs, and the only way to do that is with massive

new funding.

I would like to talk to you briefly about one idea that we have

been tossing around. There are many examples of how access to

treatment have been leveraged to achieve other public health goals.

The global drug facility for tuberculosis drugs, the Green Light

Committee for second-line TB drugs, which I was involved in. Each

of these programs have utilized access to treatment as a way of

pushing forward other public health goals. In other words, what I

would argue is that massive infusions for treatment can accelerate

prevention very rapidly.

We heard this story. Ninety percent of the people in Africa know

how the virus is transmitted. Less than 10 percent use condoms on

a regular basis, so it is not a matter of education and condoms. The

one thing that can change behavior more than anything else is

knowing your serostatus, and that we can do with VCT.

What brings people to VCT? It is treatment. Back in 1990, when

I was caring for my patients with HIV in a hospital, it was very

difficult to get them to get tested. Of course, there was really very

little we had to offer them. In Haiti, in Brazil, in Botswana, in

every situation where you look in which treatment is offered, the

voluntary counseling and testing centers are swamped. This is the

way, if you do not want to think about it as a treatment program,

think about it as a prevention acceleration program. We need to do

both of those things absolutely immediately.

161

Thank you very much.

[The prepared statement of Dr. Kim follows:]

PREPARED STATEMENT OF JIM YONG KIM, M.D., PH.D, DIRECTOR, PROGRAM IN

INFECTIOUS DISEASE AND SOCIAL CHANGE, HARVARD MEDICAL SCHOOL

INTRODUCTION

I would like to begin by thanking Senator Feingold for inviting me to testify for

such an important hearing. I applaud you for taking so seriously the problem of

AIDS in Africa.

In 1348 Europe was devastated by the first attack of Yersinia pestis or Black

Death. For almost 300 years plague terrorized communities with profound consequences for the social and economic organization of Europe. Doctors could offer

nothing for those infected, and perhaps as many as 40 million perished. At the time,

city officials would resort to burning masses of people alive, a method considered

a rational public health strategy, to protect their cities from the epidemic. Other defensive measures taken in the fourteenth and fifteenth centuries to prevent the

rapid spread of bubonic plague included banishing those in society who followed irregular life-styles seen as offensive to God, partaking in public processions to appease angry deities, and awaiting a realignment of the planets. Wealthy people of

the time sought to avoid the plague by running away from it ‘‘by fleeing early, fleeing far, and returning late.’’ 1 Despite all these efforts, recurrent waves of bubonic

plague ravaged Europe and the Middle East for centuries.2

AIDS has already claimed the lives of 26 million people and 40 million others are

infected. Unless drastic measures are taken, AIDS will become a catastrophic epidemic on the scale of the Black Death. Yet comparisons to historical epidemics like

the plague do not capture the true tragedy of AIDS. Health officials 600 years ago

did not know how plague was transmitted, much less have a access to a series of

interventions to mitigate its effects. In the 14th century, health officials were unable

to implement successful measures to end the plague because they lacked knowledge.

Today, we have the knowledge, the medical tools, and the means to change the

course of the AIDS pandemic. What we lack is the conviction and determination to

adopt courageous new measures and rally the resources to implement them. However, unless we adopt these new measures without delay, AIDS will soon become

the worst public health catastrophe of all time. If we fail to act, the next decades

of the AIDS pandemic will not be examined by future historians as a tragedy of ignorance so much as one of cold indifference to its victims, over 90 percent of whom

live in resource poor settings, most notably in sub-Saharan Africa. While we are not

burning people alive as our predecessors did during the Black Death, we are standing by as over 17,000 people become infected and 8,000 people die every day of a

miserable disease we have the tools to prevent and treat.

Even as recently as two years ago, we did not possess the means to control the

pandemic—the medications were too costly and there was no way to responsibly administer therapy and coordinate prevention. Now, we have the knowledge to proceed. We understand, for example, the promises and limitations of prevention programs based on behavioral change and risk reduction. And we have learned that

prevention efforts alone have not altered the course of the epidemic, especially in

many high HIV-prevalence areas. But, as of 1996, we have new triple combination

therapies that when integrated into comprehensive AIDS control programs have the

potential to reduce dramatically AIDS morbidity and mortality—as these medicines

have done in the United States and Europe. Prior to May 2000, one of the chief obstacles to the widespread distribution and use of these treatments was their exorbitant price. But in the last two years, the cost of the antiretroviral drugs has fallen

over 95 percent. Regimens that once cost in excess of $10,000 are now available for

less than $400 annually. Moreover, new drug regimens to fight AIDS are far simpler

to take—requiring only two or three pills two or three times daily—and come with

fewer side effects than previous combination therapies. Other obstacles preventing

resource poor areas from adopting comprehensive AIDS control programs are rapidly being overcome. This testimony provides a scientific review of the evidence supporting the case for intensified efforts and greater funding for AIDS prevention,

care, and, importantly, treatment in sub-Saharan Africa.

INSTITUTIONAL PROFILE 15 YEARS OF PROVIDING HEALTHCARE FOR THE POOR

Partners In Health is a non-profit charity dedicated to providing high quality

medical care for people living in poverty. Since its foundation in 1987, PIH has

worked with resource poor communities ranging from inner city Boston to rural

Haiti, tackling diseases such as multidrug-resistant tuberculosis (MDR-TB) and

162

HIV/AIDS. Each intervention is based on an assessment of the disease burden of

the community, a process that focuses on creating partnerships and fostering the

full participation of the local community. In our 15 years of experience working in

conditions of severe deprivation PIH has developed practical experience in implementing complex health interventions in poor settings. We have learned that the

diseases that are devastating many populations, often in the most poverty stricken

areas of the world, are no longer treatable by simple methods and quick solutions.

Treatments involve more than the provision of drugs; they necessitate the creation

of infrastructure and human capacity.

Since 1996 PIH has been working with community based organizations in Lima,

Peru to provide treatment for multidrug-resistant tuberculosis. The program serves

patients living in squatter settlements built into barren rocky hills surrounding the

City of Lima. Treatment requires the use of weaker medications with serious side

effects for up to two years. A single course of therapy cost over $15,000 when the

program began. When we announced our intention to treat MDR-TB, the global TB

community said it could not be done. Critics maintained that the infrastructure

didn’t exist, the drugs were too expensive, the clinical work too complex and the

medicines too toxic. Nonetheless, PIH began treatment using nurses, students, and

community health workers to provide directly observed therapy. International collaborations provided laboratory support, and dedicated staff developed algorithms

that since then have been expanded to a national level. The treatment results from

the first cohort of patients were very good; 85% successfully cured—a rate rarely

achieved in the developed world. We paid for the medications through the generosity

of individual donors at first, but once the program proved that MDR-TB could be

treated in poor settings the WHO established a mechanism for pooled drug procurement that slashed prices by as much as 97%. Today, 11 national TB programs have

accessed these drugs and more applications are pending.

MDR-TB treatment is a very difficult and complicated intervention. In our experience, antiretroviral therapy, by comparison, is significantly less challenging to implement, but potentially more difficult to sustain. HIV treatment must continue indefinitely, while MDR-TB typically involves 18-24 months of therapy for each patient In 1998 we translated our experience with MDR-TB to a rural community in

Haiti and began one of the first ARV therapy programs in developing countries. Unable to offer the technologically advanced viral load assays and CD4 cell counts that

are the hallmark of ARV programs in developed nations, physicians relied on clinical presentation to treat patients. To create an atmosphere of support and care,

PIH used directly observed therapy to administer medications. Our regimens involve

taking pills twice a day and the community health worker directly observes the

morning dose while providing social support and monitoring adherence and side effects.

Haiti has a per capita gross domestic product below that of many sub-Saharan

African nations. Access to our clinic, only 60 miles from an international airport,

involves a four-hour car trip over roads four-wheel drive vehicles can barely navigate. The public health infrastructure is deplorable, with the nearest hospital almost one and half hours away; there is no sanitation and only partial access to safe

water. Therapy for a single patient cost $10,000 per year when we began, but PIH

firmly believed that drug costs would fall and support would blossom if proof

emerged that ARV therapy is possible in settings of poverty. After three years of

treatment PIH was able to transport biological samples to the Harvard AIDS Institute to analyze viral loads, CD4 cell counts, and check for resistance. The results

were spectacular, with 84% of the first cohort achieving viral suppression. Resistance was found in only three patients, and none of the mutations were a threat to

the efficacy of treatment. But the effects of our program extended much beyond the

patients treated. Rates of voluntary testing and counseling sky rocketed, and prevention efforts expanded significantly. People began to search out information about

the disease because they wanted to protect themselves and their families. Treatment, even for such a small cohort, brought hope and inspiration to the region and

people saw the disease in a new light. Throughout the world communities like ours

are desperately seeking medications that we know the international community can

safely deliver. All that remains is marshaling the political will and funding to expand pilot efforts like our own.

1. THE SYNERGY OF PREVENTION AND TREATMENT

Most AIDS specialists now dismiss old debates suggesting that resources should

be devoted to prevention efforts rather than to the provision of treatment. Public

health and medical professionals now appreciate that AIDS prevention measures

are enhanced and rendered far more effective when AIDS treatment is made availVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00166 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
163

able—even in poor regions of the world. Lamenting the old polemics of the debate

between prevention and treatment, Peter Piot, the Director of UNAIDS reported recently:

In the South, the slogan ‘‘prevention is the only cure’’ began to sound like

the hypocritical justification of a morally bankrupt global divide. Inadequate access to the treatments that have transformed AIDS in rich countries is tantamount to robbing poor ones both of a powerful weapon against

the epidemic, and of hope in collective action.3

Scientific analyses support the growing consensus that AIDS prevention and

treatment strategies work best when linked and integrated into a comprehensive

AIDS program. Such analyses are typically organized under four distinct themes

(see table 1), which we will address in turn.

TABLE 1.—Treatment and Prevention are both essential to an AIDS control Program

• Prevention alone is insufficient to control HIV in highly impacted areas.

• Treatment enhances the effectiveness of voluntary counseling and testing

(VCT).

• Treatment reduces viral load, which reduces transmissibility.

• Treatment prevents maternal to child transmission of HIV.

1.1 Prevention Alone is Insufficient to Control HIV in High Prevalence Areas

Epidemiological modeling confirms that once an epidemic becomes generalized, effective prevention becomes more difficult. In other words, prevention campaigns in

regions with late stage HIV epidemics, in which large numbers of the population

are infected, may have a minimal impact on lowering HIV incidence.4 Even dramatic increases in condom usage may have little mitigating effect in high-risk areas

because those infected are now a reservoir of potential infections.

Of the 11 major randomized controlled trials examining the effectiveness of HIV

prevention interventions completed by 2001, none had successfully demonstrated an

impact on HIV incidence.5 This is not to say that prevention is ineffective, but rather to emphasize that the most dramatic benefits occur in populations with low disease prevalence. Moreover, prevention efforts are most successful when they are tailored to the specific needs of a population; when they account for the population’s

baseline HIV and STI prevalence, interactions between high-risk groups and the

general population, urban/rural population patterns, socioeconomic variables, and

sociocultural dynamics between genders and generations. Implementing ongoing and

effective prevention programs that account for these variables is challenging and absolutely necessary but, unfortunately, they are not likely to turn the tide of the epidemic without other interventions like treatment.

Even the most successful prevention campaigns to date in high prevalence countries have had mixed results. The Ugandan national AIDS program, initiated in

1986, successfully decreased prevalence from 18% in 1995 to 8% in 2000.6 Uganda

achieved success through broad, multi-sectoral approaches and political commitment. Local districts had autonomy in implementation and used coalitions among

non-traditional social structures to help mobilize mass awareness.7 The treatment

of sexually transmitted infections and targeted interventions in high-risk populations, were combined with ongoing AIDS education and support. Yet, even the dramatic gains of the Ugandan program cannot erase the fact that 8% of the population

is still fatally infected with HIV—a rate that has remained constant for two years,

suggesting that the limits of prevention may have been reached. Uganda continues

to be a pioneer in AIDS control. In response to the reality of sustained HIV infections in the country, the government has instituted one of the first antiretroviral

(ARV) treatment programs in sub-Saharan Africa. Even so, less than 10,000 patients are enrolled, a mere fraction of those in need.

1.2 Treatment Enhances Prevention

In June 2001, government envoys of 189 States and Governments, dignitaries

from around the world, and representatives from a legion of non-governmental organizations and special interest groups met in a United Nations General Assembly

Special Session devoted to developing new strategies to control the global AIDS pandemic. In their resolution, adopted by the General Assembly, representatives recognized that:

Care, support, and treatment can contribute to effective prevention

through an increased acceptance of voluntary and confidential counseling

and testing, and by keeping people living with HIV/AIDS and vulnerable

164

groups in dose contact with health-care systems and facilitating their access

to information, counseling and preventive supplies.

Current studies from several African countries report very high knowledge about

AIDS and basic understanding of how the disease is transmitted. Some researchers

estimate that 90% of African people today know how AIDS is spread and that

condoms can prevent transmission. And yet barely 10% of the populations of most

countries regularly uses condoms. Moreover, approximately 95% of people in Africa

are unaware of their HIV status.8 Data from voluntary counseling and testing programs throughout the continent suggest that knowledge of serostatus is the most

effective way to catalyze behavioral changes But what incentive does one have to

be tested, to learn of one’s HIV status, if those with the disease remain highly stigmatized and marginalized from society? If one is tested and learns that they are

indeed infected, without treatment what hope do they have for their future? Based

on our experience treating AIDS in rural Haiti and those of similar programs

around the world, patients are much more likely to change their behavior if they

have hope. The availability of AIDS treatment encourages individuals to step forward for voluntary AIDS counseling and testing, because even if they test positive

they have hope for a long and productive life.

Scientists credit the availability of voluntary counseling and testing to the overall

success of the Ugandan AIDS program.10 The efficacy of VCT in promoting risk reduction has been established through randomized clinical trials,11 allowing those

who know their infection status to avoid infecting others, while individuals testing

negative can protect themselves.12 Testing allows pregnant women to access

antiretroviral prophylaxis to prevent maternal-to-child transmission13 and counseling mitigates fears of dying and abandonment through active support. It encourages high-risk populations to learn risk reduction strategies and promotes decreased

numbers of sexual partners and increased condom usage in the general population.

In Zimbabwe, one study showed that work place prevention strategies based on such

counseling paradigms reduced HIV incidence by 30%.14

Without the promise of medical care and the possibility of receiving life prolonging

and improving drugs, individuals have little incentive to be tested for HIV when the

consequences of a positive test are rejection and isolation. Evidence from Haiti reflects this. When our clinic began to offer ARV treatment, the percentage of our patients choosing to be tested and counseled increased dramatically. Similar results

are being reported from ARV programs in countries in Africa.15

1.3 Treatment Reduces Viral Load, Which Lowers Transmission

Antiretroviral therapy reduces the viral load by preventing the virus from reproducing in the body. Reduced viral loads have been linked to decreased likelihood of

transmission. This means that patients on ARV therapy may be less likely to transmit the virus to uninfected partners. An important study from Uganda followed over

400 couples, in which one partner was HIV positive and one partner was HIV negative. The rate of transmission among this cohort was correlated with viral load levels; the more virus a person has in their body the more likely they are to transmit

the disease.16 Commentators on this study noted that the potential impact of this

information on those already infected could be significant The majority of disease

transmission occurs from a relatively small sub-set of the population, and reducing

their infectiousness could have dramatic results on overall incidence in a population.17 We now know that reduced viral load decreases transmission of the disease. ARV therapy reduces viral load, therefore, treatment may reduce the spread

of disease. It is important to note that data from San Francisco suggests that once

perceived risk of transmission is reduced through providing treatment, the level of

high-risk activity in specific populations increased.18 This emphasizes the need to

link treatment and prevention in a single, comprehensive AIDS program.

1.4 Mother To Child Transmission (MTCT)

In sub-Saharan Africa, among the 26 million women who were pregnant

in 2001, more than 2.5 million carried HIV. Assuming a rate of 20 percent

for mother-to-child transmission of HIV, we can foresee that more than

500,000 babies born to these mothers will be infected. Many of these infants, as well as the luckier 80 percent who are not themselves infected at

birth, are likely to be motherless by the time they can walk.

—MTCT-Plus Program Brochure19

In 1994 zidovudine, or AZT, was reported to reduce the transmission of HIV-1

from mother to child.20 Since that study, the average rate of MTCT in the United

States has fallen to just 3%. Since then new drugs have resulted in efficacious

therapies that require as little as a single dose delivered to a mother during labor.21

165

These life saving advances can prevent the spread of disease to a generation of unborn children. Pilot projects for the delivery of MTCT exist throughout sub-Saharan

Africa, but to integrate prevention and treatment these sites must be expanded.

It is important to remember that while short-term prophylactic measures to prevent transmission are important, it is also essential to promote the health and survival of the family unit through increased access to effective HIV treatment. Few

programs provide ARV therapy to recent mothers, and without new drugs these

women have little hope to provide a stable future for their children. As a comprehensive global AIDS strategy is developed, focus on the reduction of maternal

viral load will also decrease the high rate of adult transmission in the community

and prolong the disease-free survival and ongoing social contributions of women of

childbearing age.

1.5 The Peril of Prevention Alone

An AIDS control program that excludes treatment fails to account for the perilous

ramifications of a rapidly spreading fatal disease. Without treatment, health professionals, educators, agriculturists, political and business leaders living with AIDS

will continue to perish en masse. When infection rates reach levels in excess of 20-

30%—as they already have in many African countries—the future socioeconomic viability and political stability of entire African nations are threatened. Agricultural

productivity in the hardest hit areas of Africa, a major source of food and economic

stability, is seriously compromised due to sickness and death from the AIDS pandemic. The Food and Agriculture Organization of the United Nations released a

1999 report emphasizing the dramatic consequences of the disease on rural production.22 Due to deprivation and poverty associated with the loss of parents, orphans

are at higher risk for malnutrition, illness, and illiteracy. Rather than becoming productive members of society they often become a drain on already strained resources.

Worse, desperation can force children into prostitution and drug use, driving the

epidemic forward. The social consequences of 13 million orphans are already profound. What will the continent look like when 40 million children are orphaned, as

UNAIDS predicts for Africa in the year 2010? The manifestations of an AIDS control policy that ignores treatment are difficult to quantify but horrific to imagine.

Public policy that refuses to recognize the necessity of providing ARV therapy not

only ignores scientific evidence linking prevention and treatment, but it fails to

grasp the long-term socioeconomic and geopolitical consequences of 65 million people

dying in a single generation.

2. ANTIRETROVIRAL DRUG RESISTANCE

2.1 Therapeutic Advances and Drug Resistance

The introduction of antiretroviral therapy can directly inhibit HIV replication.

However, the effectiveness of a single drug on the clinical outcome of AIDS is limited. HIV can quickly generate resistance to drug therapy because it is a virus that

replicates very quickly with lots of random mutations. A small number of these

mutations may result in new strains of the virus that are resistant to one or more

antiretroviral drugs. When a patient is prescribed ARV therapy using only one or

two drugs (mono- and dual-therapy), the virus is capable of randomly developing resistance thus rendering that specific treatment ineffective. However, if a patient is

taking multiple medications aimed to attack the virus at different stages of its

lifecycle (the so called AIDS ‘‘cocktail’’), then a virus resistant to one type of

antiretroviral is destroyed by another. This has led to new therapeutic strategies in

which at least three drugs are prescribed simultaneously. The presence of a third

antiretroviral drug dramatically reduces the likelihood of resistance. Although ARV

therapy today is very successful at lowering AIDS related morbidity and mortality

in developed countries, it is by no means a simple solution to the AIDS pandemic.

Fortunately, there are ways of preventing antiretroviral drug resistance.

TABLE 2.—Preventing Antiretroviral Drug Resistance

• Simplified pill counts facilitate adherence.

• New drugs have better side effect profiles.

• Improved drug regimens helps to prevent resistance.

• Clinical management strategies such as Directly Observed Therapy and peer

support groups create supportive environments that encourage patient drug adherence.

• Stable drug supply and procurement reduce supply interruptions.

The successful administration of ARV therapy requires that patients have uninterrupted access to medications and ongoing social support to ensure that doses are

166

not missed. Patients’ nonadherence, or failure to take drugs precisely as prescribed,

must be avoided to limit the development of resistance. The negative consequences

of drug resistance include medication failure, spread of resistant disease to others,

disease progression and death. A decrease in adherence by as little as 10 percent

has been associated with a doubling of viral load, the most important indicator of

treatment effectiveness.23 Further, even with strong adherence to medications, a

significant long-term risk of developing resistance remains. Slight variations in dosing provide the virus with a window of opportunity to mutate into a resistant strain.

Moreover, successful long-term viral suppression requires that patients adhere extremely closely to their drug therapies.24

2.2 Strategies to Control Resistance

The lessons learned from the first stages of drug development and treatment hold

the key to preventing new forms of resistance in future populations. Early clinical

trials using mono- and dual-therapy led to the development of resistance in the

United States and Europe when no alternative therapies existed. Consequently,

many American and European populations now have high levels of drug resistance,

which complicates therapy and threatens the viability of clinical care. Emphasizing

the rational use of drugs can reduce prescriptions of inadequate regimens and encourage powerful drug combinations capable of suppressing antiretroviral drug resistance.

New generations of less toxic medications help patients adhere to their drug regimens by reducing side effects and pill count. Just a few years ago many people living with AIDS in the United States were prescribed as many as 33 pills, to be taken

in several intervals, throughout the day. Other regimens required 14 pills, three

times a day. Today, one of the most common drug regimens is quite simple. Patients

take a total of one tablet in the morning and four tablets at night.25 An important

AIDS drug, efavirenz, was approved last summer in a once daily formulation.26 New

combination tablets combining more than one agent in a single pill, such as

Combivir (two drugs) and Trizivir (three drugs), along with blister packs that contain each of the pills required in a day, greatly simplify and facilitate therapy adherence. Such strategies have also proven successful in malaria and TB treatment

programs.27 In Africa, where exposure to one and two drug combinations is historically extremely low, initiating treatment programs with triple therapy could improve long-term prospects of minimizing drug resistance.

To take their medications properly over long periods, most patients need supportive environments and individualized attention from caregivers. The success of

ARV therapy in controlled environments such as the penal system,28 where patient

adherence is easy to monitor and enforce, has lead to innovative strategies such as

directly observed therapy (DOT). This allows for precise monitoring of adherence

and side effects, but more importantly creates an environment of support and trust

to accompany therapy. An inner-city clinic in the United States recently used DOT

to successfully administer ARVs to patients in a community with routinely poor adherence patterns.29 Other adherence interventions and strategies that have proven

successful indude interpersonal support such as peer counseling, medication adherence counselors, support groups, and home visits.

In resource poor settings, DOT offers clinicians a cost effective mechanism to

begin therapy—even when patients reside far from health centers. Our experience

using this strategy to deliver ARVs to persons living with AIDS in rural Haiti has

been encouraging. Based on DOT by community health workers, our program trains

local residents to personally administer the daily medications. These community

health workers serve to ensure compliance with prescribed medications and provide

social support for persons living with AIDS. The creation of a stable environment

not only allows for proper medical care, but also creates community involvement

and integration around HIV prevention and care. DOT facilitates the provision of

ARV therapy in settings of extreme poverty while also preventing the emergence of

drug resistance.

2.3 Antiretroviral Anarchy: An Impetus to Action

The unfettered distribution of commercially available ARVs has lead to an explosion of diffuse and unmonitored treatment programs throughout the developing

world. Preliminary results from a study conducted by Partners In Health in July

2001 found privately funded ARV programs in operation in 38 low- to middle-income

countries, most located in sub-Saharan Africa. Without government assistance or

adequate medical oversight, these programs, often relying on inconsistent drug supplies from donations of unused drugs by patients in developed countries, will continue to use pharmaceuticals in an environment void of control. An unregulated environment in which prescribing practices, drug quality, and adherence rates are unVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00170 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
167

known and unmonitored can potentially lead to the widespread development of resistance.

Despite imaginary scenarios of massive drug resistance, we already know that

when programs are well administered and controlled treatment can be delivered

safely and responsibly. The preliminary assessment of an ARV program affiliated

with the University of Capetown, South Africa, reveals that of 104 patients who

completed 48 weeks of therapy the mean adherence was 88.6%. Data such as these,

combined with the experience of PIH, suggest that the non-governmental sector can

be a valuable resource in HIV prevention and control. The challenge is to ensure

that they do so effectively, not haphazardly.

National AIDS treatment programs in sub-Saharan Africa have begun the process

of determining what is needed to provide quality care. Uganda and Senegal have

both initiated successful small-scale ARV programs with encouraging results; in

Senegal 87% of patients achieved the target of 80% adherence.30 Even so, isolated

programs without global support face overwhelming obstacles. In Uganda only 58%

of patients enrolling in therapy were alive after 30 months.31 Cote D’Ivoire, another

nation providing ARV therapy, has also reported difficulties. Less than 40% of those

treated had viral suppression after 1 year, according to UNAIDS,32 and 57% of patients tested in Cote D’Ivoire had resistance to at least one anti-AIDS drug.33

These programs should be viewed as bold first steps in the public provision of

ARV therapy in Africa. Much can be learned from their implementation. While some

of these data suggest that poor compliance and drug resistance complicate the introduction of therapy in resource poor settings, they also indicate substantial success.

Stable distribution and financing can reduce drug supply interruptions and the need

to pay for medications that may have sewed as barriers to adherence in countries

like Senegal and Uganda. Clinical strategies including directly observed therapy

and heightened coordination with extant disease control services, such as for tuberculosis, offer the hope of integrated care capable of safely providing ARV medications. As one CDC expert recently said: ‘‘There is no moral victory when patients

die of drug sensitive disease.’’34 We have the knowledge and the tools to vastly scale

up treatment efforts in Africa.

3. INFRASTRUCTURE CONSTRAINTS

3.1 What Is Needed?

Putting into operation comprehensive AIDS control programs that effectively link

prevention and treatment poses challenges. Physicians need special training to administer ARVs and manage side effects; health sectors require modem and wellstocked laboratories to monitor patients’ viral loads and immune status; drug distribution systems need to be upgraded and safeguarded to ensure the prompt and

consistent delivery of supplies; and new mechanisms for drug adherence and clinical

effectiveness must be designed. It is not just a matter of providing antiretroviral

drugs, but also that they must be provided within a structured framework. While

daunting, these challenges are by no means insurmountable. Effective collaboration

between African national governments, international organizations, businesses, universities and NGOs can pave the way by expanding and improving existing health

infrastructures—leading not only to more effective AIDS control, but also to a legacy

of improved health for all Africans.

Our success in administering ARV therapy in the poorest region of the most impoverished country in the Western Hemisphere, Haiti, suggests that substantially

less infrastructure may be needed than is currently believed necessary.

Certainly large sections of the infrastructure necessary are inadequate or lacking

in sub-Saharan Africa. But infrastructure does exist. A brief review of the state of

infrastructure in sub-Saharan Africa reveals many deficiencies, but also many public health promises. To preclude treatment for 28.1 million Africans because they do

not have medical facilities as advanced as our own is unjust and unfair.

3.2 What Currently Exists?

I can be ‘‘realistic’’ and ‘‘cynical’’ with the best of them—giving all the

reasons why things are too hard to change. We must dream a bit, not beyond the feasible but to the limits of the feasible, so that we inspire.

—Jeffrey Sachs, Macroeconomics and Health: Inverting in

Health for Economic Development

In sub-Saharan Africa, a region with an average annual per capita health expenditure of $8, health systems are not yet able to provide widespread comprehensive

AIDS care. When compared to the health infrastructures found in North America

and Europe, the health sectors of most African countries are severely deficient. African health care systems do not compare favorably with those found in the world’s

168

wealthiest countries but this does not mean that the entire continent lacks the capacity to deliver high quality healthcare. Four times the size of the United States,

the continent is diverse in every conceivable way, including its health systems.

Many countries boast modern, even state-of-the-art healthcare facilities, while others lack the most rudimentary healthcare hardware.

In the intervening years since most African countries gained independence in the

early 1960s, dramatic gains were made across the continent. Large modern hospitals

were built, research institutes established, community dispensary programs initiated, and vertical disease control programs implemented and expanded. Access to

sanitation and clean water dramatically improved.35 An analysis of the 14 sub-Saharan African nations most heavily impacted by HIV/AIDS reveals that 72% of children in these countries are vaccinated against measles every year and over 80% of

women receive some form of antenatal care. Immunization coverage is often used

as a proxy for the strength of health delivery systems; high rates reflect a network

of health clinics, a complex management system capable of delivering vaccines safely and effectively, trained staff, and reporting and accountability measures.36 Even

the poorest nations have well-established networks of primary and secondary care

facilities and virtually every country in the world has an extant branch in place to

expand childhood vaccination coverage and to fight tuberculosis, leprosy and other

communicable diseases.37

Most public sector investments in Africa are concentrated on large urban hospitals. These tertiary care facilities provide a substantial array of services and are

often affiliated with local medical schools and international institutions. Even so,

case studies of health systems in many of the poorest nations suggest that while

the components of fully functioning health system are not in place, many resources

do exist. Traditional indicators of health infrastructure do not catalog the extent of

potential treatment resources. In addition to public sector health services are systems of private providers, religious hospitals, non-governmental organization programs, industrial clinics, and international civil society volunteer groups, such as

Rotary, Lions, and Zonta. Each of these health service providers serves communities

connected through kinship and social networks that allow for rapid mobilization of

human resources (see table 3).

TABLE 3.—Non-traditional Infrastructure: Opportunities for scaling up.

• Industrial and commercial clinics.

• Pharmaceutical industry donation programs.

• Community-based organizations.

• Public-private partnerships, international collaborations.

• Existing disease infrastructure.

The World Health Organization recently released ‘‘Scaling Up,’’ 38 a report that

describes a multitude of diverse, untapped sources of infrastructure that provide clinicians potential platforms to launch comprehensive AIDS control programs that include treatment. For example, Zimbabwe has 1,080 health facilities providing outpatient care, of which 72% are government sponsored. In regions where services are

not available, the Ministry of Health contracts with private hospitals to provide

health care. Such models enable rural inhabitants and industrial workers access to

care that was reserved previously only for those who could afford private healthcare.

They also demonstrate the potential for public-private partnerships in the coordination of healthcare services.

Industrial Infrastructure

Corporations throughout the continent are facing labor crises due to the devastation caused by HIV/AIDS. As a result, several large companies have begun providing

AIDS prevention and treatment to their workers. For example, Debswana, an African mining consortium and the largest employer in Botswana, declared in May 2001

that it would pay 90% of the cost of AIDS care and treatment, including ARVs, for

workers and their families. A few car manufacturers and other mining companies

in southern Africa are beginning to follow suit. Coca Cola has committed to using

its vast distribution networks and social marketing to increase AIDS awareness

through prevention campaigns. Several public utilities have also successfully

launched AIDS prevention programs for their workers.

Pharmaceutical Programs

Some research-based pharmaceutical companies have indicated a willingness to

donate drugs for treatment programs in poor communities. Historical commitments

such as Merck’s Mectizan Program to fight river blindness, and other recent initiatives in sub-Saharan Africa to treat HIV, indicate promising corporate investments

169

in global public health. Secure the Future is a $100 million donation program initiated by Bristol Myers and Squibb. Moreover, GlaxoSmithKline has now licensed generic manufactures to produce their key ARVs in South Africa, and BoehringerIngleheim has offered free ARVs to prevent mother-to-child transmission.

Community Based Organizations

Community-based organizations, women’s organizations, village councils, youth

groups, and professional trade unions are all important components of sub-Saharan

Africa’s social structure. Kinship ties and regional networks offer vast opportunities

for the organizing community outreach and training of local health workers and volunteers. In Uganda, TASO is an organization of persons living with AIDS that has

been instrumental in coordinating the sustained government commitment to fighting HIV in the country. DOTS programs in South Africa have capitalized on the social organization of women to incorporate civic groups in the administration and

monitoring of tuberculosis medications. Recent interventions initiated through trade

unions have brought condom promotion to mining camps.

Public-Private Partnerships, International Collaborations

Public private partnerships and institutional collaborations offer new hope for future AIDS control efforts. The Netherlands, Australia, and Thailand initiated a program entitled HIV-NAT to address the burgeoning epidemic through operational research and antiretroviral therapy in Southeast Asia. As a result of new capacity and

expertise, Thailand recently agreed to help Zimbabwe produce generic ARVs for domestic use, and if successful intends to offer the service to other African nations

such as Ghana. Similary, directors of the Brazilian National AIDS Program have

hosted groups from southern African countries to inspect aspects of their comprehensive, universally available AIDS program. Latin American nations such as

Guatemala, which seeks to capitalize on the Brazilian experience, are being offered

technical assistance from the Brazilian Ministry of Health on drug production and

distribution. In addition, a coalition between an African government, a pharmaceutical multinational corporation and a private foundation—the government of Botswana, Merck, and the Bill & Melinda Gates Foundation—is currently in the final

stages of introducing what will likely become Africa’s first, universal HIV/AIDS

treatment program.

Existing Disease Infrastructure

Precedents exist throughout Africa for the successful introduction of resource intensive health interventions. The STOP TB Initiative and the Expanded Program

for Immunizations (EPI) are two examples. Each of these interventions, undertaken

in almost every African nation, worked with and built upon the limited local infrastructure, ultimately creating new public health networks and resources. The STOP

TB initiative relied upon community health workers to implement DOTS, covering

over 50% of the African people.39 In the 1980s and 90s, the EPI established networks of cold chains capable of delivering environmentally sensitive vaccines, even

to remote areas throughout Africa. It also created immunization management and

monitoring systems to record use and coverage. Although immunization rates have

fallen in many parts of the developing world in recent years, a new, bolder initiative

to improve childhood immunization coverage, the Global Alliance for Vaccines and

Immunizations (GAVI) is providing new mechanisms for rapid infusions of infrastructure and material support.

One of the cornerstones of effective prevention is the administration of ARVs to

pregnant mothers. Just a single dose of Nevaripine, a potent new drug, can substantially reduce the likelihood of mother-to-child transmission (MTCT) of HIV. Across

the continent, systems of clinics capable of providing counseling, testing, and interventions are being put into place. This network has organized an initiative called

the MTCT Plus program. This will provide an estimated $100 million to link prevention of MTCT to the treatment of the mother with ARV therapy. Funding proposals

for treatment at clinics already providing services have already been received, and

treatment should be initiated by summer 2002.

3.3 What Can Be Done?

Innovative programs to address structural deficiencies in health care are being

implemented in several African countries. While current health infrastructure remains inadequate in most regions, a substantial foundation for future investments

has been laid. A comprehensive review of strategies addressing structural deficiencies by the Commission for Macroeconomics and Health (CMH) identified proven

interventions to overcome infrastructure constraints.40 Limitations on program capacity based on weak health systems can be addressed through modem management

techniques. The implementation of tuberculosis control programs in Malawi and the

170

revitalization of primary health care in Tanzania are excellent examples of dramatic

infrastructure improvement in two of the poorest nations in sub-Saharan Africa.

Many of the interventions necessary for AIDS control do not require the extensive

facilities of modem hospitals, but can be effectively administered through small clinics and dispensaries. The CMH study refers to these as dose-to-client (CTC) systems

and suggests that increasing the capacity of these local clinics and dispensaries

through stable financing is well within the ability of an international effort. Crucial

to the success of such a program is the integration and mobilization of broad public

and private partnerships. Scaling up CTC will require investments in health personnel, and improvements in physical structures, transportation, and telecommunications. It will also involve integration with national drug distribution and

warehousing. Although it may not be possible to rapidly create a system that functions flawlessly, it is well within the ‘‘absorption capacity’’ of developing nations to

steadily increase their levels of health investment.

Since gaining its independence in 1961, the country of Tanzania began to aggressively improve health systems and services. Today, the legacy of these investments

is a pyramidical structure of healthcare integrating village level dispensaries to district hospitals and national tertiary care facilities. The government operates 86 hospitals, and non-governmental organizations, religious charities, and the private sector contribute an additional 93 health facilities. Throughout the country there are

almost 5,000 health clinics and 90% of the population lives within 10 km of a health

facility.41 Through this extensive healthcare network, 90% of pregnant women receive antenatal care and 74% have a trained medical person with her at delivery.

These resources exist in a nation with a per capita grossdomestic product of under

$240.

The success of Tanzania’s health reform was based on new development strategies

such as the Sector Wide Approach (SWAP) and strong donor support. SWAP pools

donor funding for development projects into a centralized resource under the jurisdiction of the Ministry of Health. The Ministry then has discretion to invest the

funds in a coordinated manor as they see fit The donor community remains involved

as consultants, however the principle responsibility for management and accountability is transferred to the government. The aim of SWAP programs is to eliminate

fragmentation, duplication, and inefficiencies in healthcare delivery. The Swiss government became actively involved in supporting this initiative through a funding

agreement secured in bilateral negotiations.

Malawi is one of Africa’s poorest countries, with a gross domestic product of just $190 and an HIV seroprevalence rate of 16%. The dramatic increase in HIV in the

last decade triggered a corresponding rise in TB rates throughout the country. The

basic control mechanism for tuberculosis is a protocol called directly observed therapy, short-course (DOTS). This strategy is a clinical algorithm, endorsed by the

WHO, in which a trained health worker administers a standardized regimen of

drugs over a period of 6 months. Laboratory capacity, patient drug adherence, resistance prevention, and infrastructure are all necessary for a successful TB control

program. In 1985 Malawi began a partnership with the International Union against

Tuberculosis and Lung Disease (IUATLD) in order to effectively care for those infected. Malawi has 43 hospitals and 45 laboratories. The TB program required each

of these facilities to increase human resource capacity and to train staff in multidisciplinary fields. Approximately 35% of the medical care provided in Malawi is run

by non-governmental agencies and partnerships between health facilities were needed to increase coverage rates. Members of local family networks and businesses

were enlisted to serve as volunteer health workers. Operational research identified

innovative mechanisms to use social and civic resources for health delivery, including a network of 50,000 traditional healers.42

Malawi and Tanzania are two of the most impoverished countries in sub-Saharan

Africa, and yet despite high prevalence of HIV each has successfully addressed deficiencies in their healthcare systems and found solutions to expand the scope and

quality of care. Critical shortages in resources may exist, but contrary to some critics, health infrastructure exists and can be built upon in the coordination AIDS programs.

The pandemic in Africa cannot be controlled without investments in health and

social services. Expert modeling of the epidemic suggests that the disease is still in

the middle stages of development.43 Without action, the continued spread of AIDS

will further jeopardize the health systems of sub-Saharan Africa. The strain of AIDS

on local services is already dramatic; AIDS not only increases morbidity in the region and stresses already weak systems, it also takes a severe toll among health

workers themselves. New strategies of operational research, global lending paradigms, collaborations and partnerships, and coordination of diverse resources offer

a basis from which treatment can be introduced. Interventions would begin on a

171

small scale in communities with infrastructure in place. A strategy carefully

planned growth would allow these sites to expand coverage quickly, leveraging their

success to train new health workers and and increase access to care and treatment.

4. AIDS PROGRAM FOR PREVENTION AND ACCESS TO CARE AND TREATMENT AIDS PACT

The struggle to improve access to care in sub-Saharan Africa has lead to the identification of infrastructure constraints, the threat of resistance, and concerns over

the long-term sustainability of both treatment and prevention. Each of these barriers to care is real and presents the international community with a serious challenge. Significant logistical complexities are involved in connecting multiple sources

of pharmaceutical and other products with multiple needs and varying capabilities

of poor communities and individual patients on the ground.

Yet, several programs in the past decade have shown that drugs and vaccines can

be successfully delivered to people in resource-poor countries through innovative

partnerships.44 The programs include: i) the Mectizan Donation Program, which

prevents blindness by providing the drug, ivermectin, to 22 million people annually

in Africa and Latin America to treat river blindness (onchocerciasis); ii) the International Trachoma Initiative, which provides the drug, azithromycin, to treat trachoma and thereby prevent another major cause of blindness; iii) the Global Alliance

for Vaccines and Immunization (GAVI), which currently provides vaccines and support for vaccine programs to 36 countries; iv) the Green Light Committee (GLC) for

Tuberculosis, which provides specialized drugs for the treatment of multidrug-resistant tuberculosis to many countries; and v) the Global TB Drug Facility (GDF),

which provides TB drugs to programs employing Directly Observed Therapy, Shortcourse (DOTS) in 5 countries. Partners in Health has recently been working with

a small group of physicians, health policy experts, social scientists and management

consultants to study these existing programs and develop a similar mechanism that

will link HIV treatment with prevention and assure a long-term sustainable supply

of low-cost, high-quality ARV’s for resource-poor settings. We have called this mechanism the AIDS PACT (Prevention and Access to Care and Treatment).

I have had the privilege of being involved in the genesis of the WHO’s Green

Light Committee, which was an initiative linking treatment and prevention to control MDR-TB. In 1999, recognizing the potential gravity of a drug-resistant airborne

infectious disease such as MDR-TB, the World Health Organization resolved to address the principle obstacles to developing effective treatment programs in highly

affected areas. The WHO program faced constraints similar to those we are currently encountering with HIV: inadequate infrastructure to implement complex clinical regimens; the potential threat of developing further drug resistance; and the

cost and supply of medications.

To overcome these obstacles an organization now known as the Green Light Committee (GLC) was formed. This body fulfills two key functions: 1) by pooling demand

and creating a competitive market environment it leveraged massive reductions in

drug prices while assuring quality; and 2) by making access to preferentially priced

drugs conditional upon program requirements it ensured rational use and minimized drug resistance. A scientific committee encourages and provides support for

the development of adequate program infrastructure and clinical supervision

throughout the application process. Government funding proposals are reviewed in

light of criteria associated with international guidelines for MDR-TB management.

All projects that are approved are quality-assured through their duration, and monitored for continued compliance.

The results have lead to minimum price reductions of 40% on single drugs and

discounts up to as much as 99% for others. Net drug costs for some participating

Ministries of Health have diminished over 96%. The funds saved on procurement

are then available for investment in other aspects of tuberculosis control. The GLC

faced a paradoxical challenge: increase access to medicines by decreasing prices, and

increase regulatory control over these same drugs. Market consolidation achieved

the first goal, and program requirements enforced by a regulatory body with technical assistance met the second.

The strength of this model derives from the ability of an international oversight

committee to apply rigorous conditions to access for medications. Such controls minimize the opportunity for resistance to develop by ensuring that the tuberculosis program involved has appropriate algorithms for treatment. To impose controls without

technical assistance would ultimately restrict access, rather than promote rational

use of pharmaceuticals. Accordingly, any project initially unable to qualify can ask

for technical assistance to meet eligibility requirements.

172

TABLE 4.—AIDS PACT

• Pooled procurment of both branded and generic drugs combined with strong

quality control assures low prices, high quality and a long-term sutainable supply.

• Technical assistance through grant and loan mechanisms ensure rational use

of drugs and capacity building.

• Linking treatment to prevention provides the best possible chance for controlling the epidemic.

The management of MDR-TB treatment programs through the GLC offers lessons

for the challenge of delivering HIV/AIDS treatment to poor communities worldwide.

The current barriers to effective AIDS treatment programs are analogous in many

ways to the conditions of the MDR-TB epidemic. Beyond parallel concerns of cost,

objections center on the problem of inadequate local infrastructure and management

capacities. Given infrastructure weakness, institutional inefficiency, and corruption,

it is argued that even if drugs for HIV were available at no cost the ‘‘systems to

deliver them are not there.’’45 This claim reflects the real gaps in poor countries’

health care delivery apparatus. Yet, their existence is not an excuse for inertia and

resignation. Non-traditional infrastructure and institutional capacity are present,

and proven mechanisms for scaling up delivery exist.

An international pooled procurement program and scientific regulatory body could

prove helpful in providing a framework for the rational introduction of therapy.

Using economies of scale and quality control mechanisms procurement agents can

purchase AIDS drugs at preferential prices. Drugs from this effort could be procured

from both the research based pharmaceutical industry and the generic drug industry. Six major research based pharmaceutical organizations have already engaged

in reduced price access to ARVs for developing countries through the Accelerating

Access Initiative. Additionally, there are at least 25 generic manufacturers engaged

in some level of ARV production. Finally, procurement must include testing kits and

laboratory reagents. Ten companies are involved in rapid HIV testing systems, 3

companies in viral load systems, and at least 8 companies providing CD4-cell count

systems. Efforts to procure these resources in a manner that will lead to a longterm supply of high-quality, low-cost drugs have been discussed in various fora but

to date no unified and coordinated system has been built.

Applicant programs would need to demonstrate the ability to meet requirements

based on international guidelines established through a panel that included medical

and public health specialists but also people living with HIV and representative of

treatment advocacy groups. Programs that express need but do not have the infrastructure can be supported through technical assistance, grants, and loans. Most importantly, access to antiretroviral therapy will be tied to high-level national commitment to prevention, care and impact-mitigation efforts. Through a mutually supportive process national AIDS plans can be designed and implemented that reflect

the need to care for those infected and prevent future spread. Treatment can act

as a catalyst for prevention programs, as well as a complement to them.

An AIDS PACT program would provide developing countries with resources to

overcome infrastructure constraints, access affordable antiretroviral therapy, and receive technical assistance to maximize the effectiveness of both treatment and prevention. Using access to medicines to influence policy can also provide the best protection against irresponsible prescribing practices, poor quality drugs, and strengthen adherence monitoring programs. This could minimize the development of drug

resistance and provide a future mechanism for the distribution of AIDS vaccines

and new pharmaceutical products as they become available. Finally, the AIDS

PACT could become a clearinghouse for operational research into best practices for

linking treatment to prevention in resource poor settings. Data from participating

sites can be aggregated and analyzed, operational research can be implemented

across regions and new regimens can be tested through institutional partnerships.

Any program such as the AIDS PACT would have to do at least two things extremely well. It would have to dramatically and quickly increase access to treatment

and at the same time link treatment to prevention. Examples of programs that do

just that exist and must be studied closely as we move forward in our efforts to respond to the AIDS catastrophe.

CONCLUSION

I am very grateful to Senator Feingold for inviting me to provide testimony to the

Senate Foreign Relations Committee. As a physician, an anthropologist and a

human being, I am convinced that what we do in response to this epidemic will define our generation. I urge you to increase dramatically our country’s financial comVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00176 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
173

mitment to fighting this epidemic. In addition to the funding provided through bilateral funding channels, I strongly support a much larger contribution to the Global

Fund to Fight AIDS, TB and Malaria (GFATM). Funds provided to the GFATM can

leverage other funding and build an appropriate level of resources so that we can

do the right thing in Africa and other parts of the world.

FOOTNOTES

1Watts, Sheldon, Epidemics and History, 1997, Yale University Press, p. 9. 2Kiple, Kenneth, ed. The Cambridge World History of Human Disease, Cambridge University

Press 1993 3Piot P, Coll Seck AM. International Response to the HIV/AIDS epidemic: Planning for Suc- cess. Bulletin of the World Health Organization 2001;79:1106. 4Grassly NC, Garnett GP, Schwartlander B, Gregson S, Anderson RM. The effectiveness of

HIV prevention and the epidemiological context. Bulletin of the World Health Organization

2001;79:1121-32. 5Grassly NC, Garnett GP, Schwartlander B, et al. The Effectiveness of HIV prevention and

the epidemiological context. Bulletin of the World Health Organization 2001;79:1121-1132. 6February 13, 2001 Internet Communication at CDC Website, country profile for Uganda

http://www.cdc.gov/nchstp/od/gap/text/countries/uganda.htm 7 0kware S, Opio A, Musinguzi J, Waibale P. Fighting HIV/AIDS: Is success possible? Bulletin

of the World Health Organization 2001;79:1113. 8World Health Organization. ‘‘Scaling Up the Response to Infectious Diseases: A Way Out of

Poverty’’ World Health Organization. Geneva, 2002. 9 Buve A. HIV/AIDS in Africa: Why so severe, why so heterogenous? Presented at the 7th Conference on Retroviruses and Opportunistic Infections, San Francisco, January 30-February 2,

2000. 10Muller 0, Barugahare L, Schwartlander B, et al. HIV prevalence, attitudes and behaviour

in clients of a confidential HIV testing and counseling centre in Uganda. AIDS 1992;6:869. 11 Voluntary Counseling and Testing Efficacy Study Group. HIV-1 risk reduction among individuals and couples receiving HIV-1 voluntary counseling and testing in three developing countries: the Voluntary HIV-1 Counseling and Testing Efficacy Study. Lancet 2000;356:103. 12 Roth DL, Stewart KE, Clay OJ, van Der Straten A, Karita E, Allen S. Sexual practices of

HIV discordant and concordant couples in Rwanda: effects of a testing and counselling programme for men. Inteniational Journal of STD and AIDS 2001;12:181-8. 13De Cock KM, Fowler MG, Mercier E, et al Prevention of mother-to-child HIV transmission

in resource poor countries: translating research into policy and practice. JAMA. 2000;283:1175-

82.14 Commission on Macroeconomics and Health. ‘‘Macroeconomics and Health: Investing in

Health for Economic Development.’’ World Health Organization. Geneva, 2001. 15Lamptey PR. Reducing heterosexual transmission of HIV in poor countries. BMJ

2002;424:207. 16Quinn TC, Wawer MJ, Sewankambo N, et al. Viral Load and Heterosexual Transmission

of Human Immunodeficiency Virus Type 1. New England Journal Medicine 2000;342:921-9. 17 Cohen M. Preventing Sexual Transmission of HIV—New Ideas from Sub-Saharan Africa.

New England Journal of Medidne 2000;342:970. 18 Blower S, Gershenghorn HB, Grant RM. A tale of two futures: HIV and antiretroviral therapy in San Francisco. Science 2000; 287:650-654. 19February 13, 2001 internet communication at: http://chaos.cpmc.columbia.edu/sph/mtct— plus—brochure.pdf. 20 Connor EM, Sperling RS, Gelber R et al. Reduction of maternal to child transmission of

human immunodeficiency virus type 1 with zidovudine treatment. New England Journal of

Medicine 1994;331:1173. 21Guay L, Musoke P, Fleming T, et al. A randomized trial of single dose nevirapine to mother

and infant versus azidothymidine in Kampala, Uganda for prevention of mother-to-child transmission of HIV–1 (HIVNET 012). In: Program and abstracts of the Second Conference on Global

Strategies for the Prevention of HIV transmission From Mothers to Infants; September 1999;

Montreal, Quebec. Abstract 013. 22FAO and UNAIDS Joint Publications Sustainable Agricultural/Rural Development and Vulnerability to the AIDS Epidemic. UNAIDS. Geneva, 1999. 23 Bangsberg DR, Hecht FM, Charlebois ED, et al. Adherence to protease inhibitors, HIV-1

viral load, and development of drug resistance in an indigent population. AIDS 2000;14:357-66. 24Paterson D, Swindells S, Mohr J, et al. How much adherence is enough? A prospective

study of adherence to protease inhibitor therapy using MEMSCaps. Sixth Conference on

Retroviruses and Opportunistic Infections.Chicago, IL 1999 (Abstract 92). 25Kim, JY ‘‘The Role of the U.S. Congress in the HIV/AIDS Pandemic: Briefing to Congress’’ July 20, 2001 26Kaiser Daily HIV/AIDS Report. February 5, 2001. 27Mehta S, Moore RD. Potential factors affecting adherence in patients with HIV therapy.

AIDS 1997;11:1665-70. 28Fischl M, Rodriguez A, Scerpela E, et al. Impact of directly observed therapy on outcomes

in HIV clinical trials. Seventh Conference on Retroviruses and Opportunistic Infections. San

Francisco, CA 2000 (Abstract WeOrB6O6). 29Stenzel MS, McKenzie M, Mitty JA, Flanigan TP. Enhancing adherence to HAART: a pilot

program of modified directly observed therapy. AIDS Reader. 2001;11:317-9, 324-8. 30 Unpublished data present 3/01 by Dr. Mame Awe Faye, Centre de Traitments

Ambulatortes, CHU de Fan, Dakar, Senegal.

174

31Willbond 13, Thottingal P, Kimani J, et al. The Evidence Base for Interventions in the Care

and Management of AIDS in Low and Middle Income Countries. Commission on Macroeconomics

and Health. Geneva, 2001. 32Djomond G, Roels T, Chorba T. Cote d’Ivory Ministry of Health—UNAIDS HIV/AIDS Drug

Access Initiative—Preliminary Report UNAIDS. Geneva, 2000. 33Willbond B, Thottingal P, Kimani J, et al. The Evidence Base for Intententions in the Care

and Management of AIDS in Low and Middle Income Countries. Commission on Macroeconomics

and Health. Geneva, 2001. 34Personal Communication. 35PANOS Institute. Beyond Our Means? The cost of treating HIV/AIDS in the developing

world. PANOS Institute. London, 2001. 36 Hanson K, Ranson K, Oliviera-Cruz V, Mills A. Contraints to scaling up health interventions: A conceptual framework and empirical analysis. Commission on Macroeconomics and

Health. Geneva, 2001. 37Data from UNICEF and WHO statistical resources. 38World Health Organization. Scaling Up the Response to Infectious Diseases: A Way Out of

Poverty. World Health Organization. Geneva, 2002. 39World Development Indicators 2001. World Bank. 40 Hanson K, Ranson K, Oliviera-Cruz V, Mills A. Contraints to scaling up health interventions: A conceptual framework and empirical analysis. Commission on Macroeconomics and

Health. Geneva, 2001. 41Gilson L. Management and Health care reform in sub-Saharan Africa. Social. Science and

Medicine 1995;40:695. 42Kelly PM. Local problems, local solutions: improving tuberculosis control at the district level

in Malawi. Bulletin of the World Health Organization 2001:79;111. 43 Roy Anderson, Lecture Transcript. 44 Reich MR. ‘‘Public-private partnerships for public health,’’ Nature Medicine 2000;6:617-620. 45Sykes R. Commentary: The reality of treating HIV/AIDS in poor countries. BMJ

2002;324:216.

Senator FEINGOLD. That is wonderful testimony. I am going to

turn now to Mr. Vorster. This is the greatest job in the world I

have here, but it can be frustrating, and they are about to start a

series of votes that is going to make it very difficult to ask questions. What I would like to ask is, if we could submit, first of all,

questions in writing to you if we cannot ask them, and second I am

wondering if you would be willing to meet with us in a more informal setting if we cannot reconvene the hearing so that we can pursue this discussion, because it has already been such a fine panel.

Mr. Vorster, please proceed.

STATEMENT OF MR. MARTIN J. VORSTER, MAHYENO

TRIBUTARY MAMELODI, PRETORIA, SOUTH AFRICA

Mr. VORSTER. Thank you, Mr. Chairman and committee members. I am not an expert. I am a worker, working in the grassroots

among the poor and caring for AIDS patients and children orphaned through AIDS. I do not take this privilege lightly of being

able to speak here this afternoon, particularly in view of our recent

past in South Africa.

As you will see, I am a middle-aged white South African with a

surname of Vorster, and according to my CV you will notice that

I spent many years in the military, but through faith in God I have

been turned around, and the people that I once subdued their aspirations, in believing that it was service to God, I now serve with

my family in empowering the poorest of the poor.

I also speak on behalf of our poor particularly in South Africa.

I speak on behalf of the Caring for the Poor and Needy Resource

Network, which currently has 473 individuals and organizations

from amongst the poor, representing 78 countries. And 106 of these

organizations are networkers from Africa.

For the past 9 years, I have worked in black townships in South

Africa, and for the past 5 my family and I have lived and worked

amongst the poor in Mamelodi. We empower the poor in marker

175

enterprises. We care for AIDS sufferers in their homes, and we parent the children orphaned through AIDS.

One of our AIDS sufferers, a single mother, had only one child,

a 7-year-old daughter, Nongani, and we prepared her as best we

could for the death of her mother, as much as one can for a child

of that age, yet when the mother died, the trauma that this little

girl experienced in being wrenched from her mother caused her to

have a stroke. It disfigured and twisted her face.

Now, there are many such heartbreaking experiences happening

throughout Africa today, but what I was asked to speak on this

afternoon was the role of faith-based organizations as well as political leadership in combating AIDS, particularly in South Africa. Up

until recently, our government has focused extensively on the prevention of AIDS, rather than on the treatment of AIDS. This prevention campaign was largely education through the media, coupled with the provision of millions of condoms. The campaign was

very controversial, yet we at the grassroots level found that it had

a positive effect in lifting the taboo around AIDS, the stigma.

Four to 5 years ago, the patients were being dismissed from hospitals in their final stages of AIDS, and often with acute diarrhea.

The families, having no knowledge of the virus, were understandably afraid, and these patients were then placed in their rooms and

all of the keyholes were sealed with tape to prevent the spread of

the disease. In many cases they were not given food or water, and

within days they would die from dehydration.

Caregivers like my wife, Terry and I were literally running from

home to home to try and save these patients from a horrible death.

On the other hand, nearly the role of the faith-based organizations

in AIDS has been largely on the treatment phase and not prevention, although this is done on an individual basis, one to one. It has

taken years, but now there is a growing recognition of government

and others that faith based organizations (FBO’s) are contributing

significantly toward the fight against HIV and AIDS.

FBO’s often reach into the most sections of society and those

most vulnerable to the epidemic. For years, this fact has been hidden, and possibly for the following reasons. No. 1, in South Africa

it is not the national religious organizations that are spearheading

this involvement, but rather individuals or small groups of people,

mostly women, who are working in obscurity in our black townships, communities, and rural areas.

No. 2, the involvement of faith-based organizations at grassroots

level was initially responsive and not proactive. As the crisis grew,

they would quietly care for those suffering and those dying, making

use of their own meager resources.

In contrast to this, we have nongovernmental organizations and

community-based organizations [CBO’s] who would first constitute

themselves, set up committees, and then seek the donations and

contributions toward their plans before any action took place. Unfortunately, it is generally the case that NGO’s and CBO’s are

founded as a means of employment, and they depend heavily on

government funding to sustain them.

The FBO’s generally continue to remain active and involved, giving sacrificially of their own capabilities and resources. FBO’s beVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00179 Fmt 6602 Sfmt 6602 77846.002 SFRELA2 PsN: SFRELA2
176

lieve that they are motivated by a call from God, and they and

their workers are prepared to depend and trust in God.

No. 3, initially there was a very slow response from the government to the AIDS crisis which left a vacuum in the townships.

Four to five years ago, the catch-phrase and the focus by the government was poverty alleviation and job creation. Funding was

made available to CBO’s involved in community development and

empowerment, and specific strategies and theories were presented

by the departments of government to implement these actions.

However, at this stage, the rate of AIDS-related deaths began to

increase, and orphans were being left to fend for themselves. The

government’s social workers were unable to meet the needs of this

new crisis simply because the format of the poverty alleviation plan

did not meet the criteria presented by the AIDS crisis. Therefore,

all funding was denied to those involved.

It was in this vacuum that many FBO’s took the initiative by

using their own resources, limited as they were. For various reasons, many FBO’s today still remain outside that circle of funding.

The government now acknowledges that although religious organizations and structures have played and continue to play a significant role in alleviating the AIDS crisis, that these FBO’s have been

very limited, due to the fact that the resources of most of these organizations are inadequate.

In spite of this, the following decisions have been made and

passed on to FBO’s. First, the government has stated that it cannot

fund religious institutions. Second, religious institutions, churches

or organizations will have to reconstitute themselves as nonprofit

organizations falling under the Department of Welfare in order to

apply for government funding. This decision can affect FBO’s negatively in cases where government policies and strategies clash with

religious beliefs or morals.

Third, it has been stated that nonprofit organizations receiving

government funding will not be able to receive funding from alternative sources.

The government has left it too late in addressing the real root

problem of AIDS, and that is that it is essentially a moral behavioral problem, and that people’s life patterns need to change. It is

reported that this is to be addressed by the government in 2002.

Although poverty is not the cause, it also plays a major role in

the spreading of the AIDS virus. As is the case with substance

abuse, one finds that those who are lower down on the poverty

scale are generally those who suffer from greater substance abuse.

In the informal settlements or slums there is primarily a lack of

adequate housing. Families often share a room. Three or four family members will share a bed, and often fornication and general immorality or abuse does take place.

The percentage per middle income household of those with HIV/

AIDS is not as high as that amongst the poor in the squatter settlements, where it is now beginning to wipe out entire families.

We have identified three categories of groups in our townships,

first the youth who are infected and are angry, some even wanting

to wilfully affect others. Second, there is the group who have been

tested positive and are remorseful, living changed, quieter lives,

and then last, the vast majority, who out of fear have not been testVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00180 Fmt 6602 Sfmt 6602 77846.002 SFRELA2 PsN: SFRELA2
177

ed and yet perhaps through knowledge of their own behavioral patterns realize that they could be infected. This is the majority, and

they live in constant fear.

The reality and the causes. The reality is that extreme poverty

does exist in Africa. In many ways, it can be attributed to colonialism and inequalities and injustices of the past and the present.

The reality also is that Africa does not just want a hand-out, but

a hand up, not just helping people, but also helping people to help

themselves. They want to be empowered. There is a strong drive

to make Africans Africans again. Under the leadership of President

Mbeki, there is a will to make Africa succeed and overcome the

manyfold problems that led to the perception of Africa being known

as the Dark Continent.

Senator FEINGOLD. Mr. Vorster, I am sorry, if you would summarize quickly, I have to leave for the floor in about a minute. I regret

this. I find your testimony very moving. So please conclude if you

could.

Mr. VORSTER. If Africa wants to emerge as a role-player in world

affairs, coupled with the African renaissance, this does have effects

onto the ground level, and perhaps to use the example of the advice

given by the traditional spiritual healers, that infected people

should have sexual intercourse with children under the age of 2

years, which was then changed to all virgins, and had astronomical

effects in our townships and is still going on today, where there is

much rape and abuse of particularly young children and newborn

babies, the dilemma is that people need to be empowered, but last

the solution is back to realism. We are all aware that within faithbased organizations and NGO’s you will still find corruption. However, because of the structure and accountability of the FBO’s as

well as the fact that in many instances the grassroots work is actually happening, that there should be a lower level of corruption in

FBO’s than in NGO’s.

The other positive point is that the chances of holistic help reaching the poorest of the poor is more likely to happen, and also where

they are at.

[The prepared statement of Mr. Vorster follows:]

PREPARED STATEMENT OF MARTIN J. VORSTER, MAHYENO COMMUNITY CARING FOR

THE POOR AND NEEDY, MAHYENO TRIBUTARY MAMELODI, SOUTH AFRICA

I speak on behalf of Africa. I do not take this privilege lightly, especially in view

of our recent South African past. As you can see, I am a white middle aged South

African. I have an Afrikaans surname, Vorster. You will notice from my CV I spent

a number of years in the military. I believed that I was doing my country—and

God—a service in subduing the aspirations of the African people. God has turned

all this around for me. Together with my family, I now live and work in a black

township empowering the ‘‘poorest of the poor.’’

I also speak on behalf of our poor; I speak on behalf of the Caring for the Poor

and Needy Resource Network (CPNRN) as a member of Mahyeno Community. The

CPNRN is a resource network for those who work with the poor.

There are currently 473 individuals and organizations amongst the poor representing 78 countries, 103 of these CPNRN Networkers are from Africa. They are

World Vision, World Relief, UNICEF, Salvation Army, and Samaritan’s Purse and

others.

For the past nine years I have worked in black townships in South Africa, for the

past five years, my family and I have lived and worked amongst the poor in

Mamelodi, near Pretoria. We empower the poor in micro enterprises; we care for

AIDS sufferers in their homes; and we parent children orphaned through AIDS. One

of our AIDS sufferers, a single mother, had only one child, a seven-year-old daughVerDate 11-MAY-2000 09:04 May 09, 2002 Jkt 000000 PO 00000 Frm 00181 Fmt 6602 Sfmt 6621 77846.002 SFRELA2 PsN: SFRELA2
178

ter, Nongani. We prepared her as best we could for the death of her mother—as much as one can for a child of that age. Yet, when the mother died, the trauma

that this little girl experienced in being wrenched from her mother caused her to

have a stroke. It disfigured and twisted her face. There are many such heartbreaking experiences happening throughout Africa today.

THE ROLE OF FAITH BASED ORGANISATIONS AND POLITICAL LEADERSHIP IN

COMBATTING AIDS

Up until recently, our government has focused extensively on the prevention of

AIDS rather than on the treatment of AIDS. This prevention campaign was largely

education through the Media, coupled with the provision of millions of condoms. The

campaign was very controversial, yet we at grassroots level found that it had a positive effect in lifting the ‘‘taboo’’ around AIDS. Four to five years ago patients were

being dismissed from hospitals in their final stages of AIDS, and often with acute

diarrohea. Their families, having no knowledge of the virus, were understandably

afraid and these patients were then placed in their rooms with all air holes and keyholes being sealed with tape to prevent the spread of the disease. In many cases

they were not given food or water and within days they would die from dehydration.

Caregivers like my wife Terry, and I were running from one home to the next trying

to save these patients from a horrible death.

On the other hand, the role of faith-based organisations (FBO’s) in AIDS has been

largely on the treatment phase and not prevention, although this is done on an individual basis—one to one. It has taken years but now there is growing recognition

from government and others that FBO’s are contributing significantly toward the

fight against HIV and AIDS. FBO’s often reach into most sections of society and

those most vulnerable to the epidemic. For years this fact has been hidden, and possibly for the following reasons:

1. It is not the national religious organisations that are spearheading this involvement, but rather individuals or small groups of people, mostly women who

are working in obscurity in our black townships, communities and rural areas.

2. The involvement of FBO’s at grassroots level was initially responsive and

not pro-active. As the crisis grew, they would quietly care for those suffering

and those dying, making use of their own meagre resources. In contrast to this

we have nongovernmental organisations (NGO’s) and community based

organisations (CBO’s) who would first constitute themselves, set up committees,

and then seek donations and contributions toward their plans, before any action

took place. Unfortunately, it is generally the case that NGO’s and CBO’s are

founded as a means of employment and they depend heavily on governmental

funding to sustain them. The FBO’s generally continue to remain active and involved, giving sacrificially of their own capabilities and resources. FBO’s believe

that they are motivated by a call from God and they, and their workers, are

prepared to depend and trust in God.

3. Initially there was a very slow response from the government to the AIDS

crisis, which left a vacuum in the townships. Four to five years ago, the catch

phrase and the focus by the government was poverty alleviation and job creation. Funding was made available to CBO’s involved in community development and empowerment, and specific strategies and theories were presented by

the departments of government to implement these actions. However, at this

stage the rate of AIDS-related deaths began to increase and orphans were being

left to fend for themselves. The government social workers were unable to meet

the needs of this new crisis simply because the format of the poverty alleviation

plan, did not meet the criteria presented by the AIDS crisis. Therefore all funding was denied to those involved. It was in this vacuum that many FBO’s took

the initiative by using their own resources, limited as they were. For various

reasons, many FBO’s today still remain outside that circle of funding.

The government now acknowledges that although religious organisations and

structures have played, and continue to play, a major role in alleviating the AIDS

crisis; that these FBO’s have been very limited due to the fact that the resources

of most of these organizations are inadequate. In spite of this, the following decisions have been made and passed on to FBO’s:

1. The government has stated that it cannot fund religious institutions.

2. Religious institutions, churches or organizations will have to reconstitute

themselves as non-profit organizations, failing under the Department of Welfare, in order to apply for government funding. (This decision can affect FBO’s

negatively in cases where government policies and strategies clash with religious beliefs or morals).

179

3. It has been stated that Non-profit Organisations (NPO’s) receiving government funding will not be able to receive funding from alternative sources.

The government has left it too late in addressing the real root problem of AIDS,

and that is, that it is essentially a moral behavioral problem, and that people’s life

patterns need to change. It is reported that this is to be addressed by the government in 2002.

Although poverty is not the cause, it also plays a major role in the spreading of

the AIDS virus. As is the case with substance abuse, one finds that those who are

lower down on the poverty scale are generally those who suffer from greater substance abuse. In the informal settlements or slums, there is primarily a lack of adequate housing. Families often share a room. Three or four family members will be

in a bed and fornication and general immorality/abuse does take place. Idleness

through unemployment, lack of running water, sanitation, electricity, etc. sometimes

leads to all forms of abuse, which in turn leads to increasing immorality. The percentage per middle-income household of those with HIV/AIDS is not as high as that

amongst the poor in the squatter settlements, where it is now beginning to wipe

out entire families.

We have identified three categories or groups in the township: firstly, the youth

who are infected, are angry, some even wanting to willfully infect others. Secondly,

there is the group who have been tested positive and are remorseful, living changed,

quieter lives. And then lastly, the vast majority, who out of fear have not been tested, and yet perhaps through knowledge of their own behavioral patterns realize that

they, could be infected. This is the majority and they live in constant fear.

Do not the struggles of these last two groups show that the motivation of the

faith-based organisations is where the answer lies?

REALITY AND CAUSES

The reality is that extreme poverty does exist in Africa. In many ways it can be

attributed to colonialism and the inequalities and injustices of the past and present.

The reality also is that Africa does not just want a handout, but a hand-up, not just

helping people but also helping the people to help themselves. They want to be empowered. There is a strong drive to make Africans, Africans again.

Under the leadership of President Mbeki there is a will to make Africa succeed

and overcome the manifold problems that led to the perception of Africa being

known as the ‘‘Dark Continent.’’ Africa wants to emerge as a significant role-player

in world affairs and to be stable, sustainable and competitive in the world markets.

In this process there is a strong reaction against being dictated to, manipulated

and coerced by particularly the Western countries.

Policies in pursuit of the African Renaissance have direct bearings on behavior

right down to grassroots level. An example of this is the acceptance and even promotion of sangomas—traditional spiritual healers—as medical alternatives in the

African culture. Despite the lack of science of these people, our leaders promote

them as being legitimate, and thousands flock to them for a cure for AIDS. Up until

recently one of the prescriptions given to AIDS sufferers in the black townships was

to have sexual intercourse with children under the age of two years. This was then

altered later to include all virgins. We have seen a sharp increase of rape and sexual abuse amongst young girls and even newborn babies.

THE DILEMMA

People need to be empowered through a participatory developmental approach.

There is place for relief aid. Donations are sometimes given in a vacuum, devoid

of structure and accountability, although possessing many good ideas and visions.

When an organisation is not able to handle the donation, this leads to temptation

to misappropriate resources.

THE SOLUTION

Back to realism! We are all aware that within faith based organisations (FBO’s)

and nongovernmental organisations (NGO’s) you will still find corruption. However,

because of the structure and accountability of FBO’s, as well as the fact that in

many instances, the actual grassroots work is already happening, (albeit in many

instances with volunteers), the level of corruption should be much lower. The other

positive point is that the chances of holistic help reaching the poorest of the poor,

is more likely to happen in a shorter space of time, as well as to reach them where

they are at.

Why am I, a white middle-aged South African, with the Afrikaans surname of

Vorster, prepared to now love and serve the very people I once loathed? It is because

180

my life was turned around by faith and repentance. Because I have seen how others

in the CPNRN, who are similarly moved by faith, have made a significant difference

in their world.

Aids is a reality! My beloved country, South Africa, cries as it buries its unnecessary dead. But with the enlightened help of our international friends, organisations

such as ours can continue to provide the added dimension in the treatment and prevention of Africa’s HIV/AIDS crisis.

I thank you.

Senator FEINGOLD. Thank you, Mr. Vorster. Let me quickly say

I am very moved by your testimony. I indicated how I felt about

Dr. Sachs’ testimony, but I also want to say Dr. Kim’s testimony,

although sometimes technical, is so important, because he is answering the question that is too often left out, and that is, how can

it be done? This committee really needs to hear that and to have

it inform our legislation.

Let me say I know that Senator Frist regrets we have to somewhat prematurely stop the hearing, and he thanks you profusely

for this very good panel and we look forward to the followup when

we ask the questions in writing, and also we want to get together

with you to talk some more, but you have been very helpful, and

I really appreciate this panel. Thank you so much.

That concludes the hearing.

[Whereupon, at 4:45 p.m., the committee adjourned.]

Æ