```

[Senate Hearing 107-330]
[From the U.S. Government Publishing Office]

                                                        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

77-846              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2002
____________________________________________________________________________
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                     COMMITTEE ON FOREIGN RELATIONS

                JOSEPH R. BIDEN, Jr., Delaware, Chairman
PAUL S. SARBANES, Maryland           JESSE HELMS, North Carolina
CHRISTOPHER J. DODD, Connecticut     RICHARD G. LUGAR, Indiana
JOHN F. KERRY, Massachusetts         CHUCK HAGEL, Nebraska
RUSSELL D. FEINGOLD, Wisconsin       GORDON H. SMITH, Oregon
PAUL D. WELLSTONE, Minnesota         BILL FRIST, Tennessee
BARBARA BOXER, California            LINCOLN D. CHAFEE, Rhode Island
ROBERT G. TORRICELLI, New Jersey     GEORGE ALLEN, Virginia
BILL NELSON, Florida                 SAM BROWNBACK, Kansas
JOHN D. ROCKEFELLER IV, West         MICHAEL B. ENZI, Wyoming
    Virginia

                     Edwin K. Hall, Staff Director
            Patricia A. McNerney, Republican Staff Director

                                  (ii)

  
?

                            C O N T E N T S

                              ----------                              

             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)

  

 
 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 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--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 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 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 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 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 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.
    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 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, multi-lateral 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 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, 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.
    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 ministers 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 onslaught 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 for-profit 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 decision-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 sub-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.

                               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.
    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?
    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 
breadwinners 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 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 significantly 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 
requested $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 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 problem. 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 faith-based 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 non-governmental organizations to provide home-based 
care.
    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 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 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 additional 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 newly-formed 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 start-up of the Global 
Fund to Fight AIDS, Tuberculosis, and Malaria.
    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.
    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 flexibility 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 several 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 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.
    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.
    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 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 disease-directed 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 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 on-the-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 contract 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 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.
    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.
    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.
    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 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 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 low-income 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 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?
    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 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.
    [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.
    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.
    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 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 representative 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.
    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.
    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 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 value-added 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.
    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.

    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.
    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.
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 Secretary-General 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 dialogue 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.

   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 Goias state to reach more women with HIV, helping them 
to avoid transmission to their babies and training them as peer 
educators.
    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.
          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 
        Organization 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.
    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 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.
    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.
    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.
    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.
    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 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.
    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 Europeans 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 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.
    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?
    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.
    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 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 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, 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.
    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 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 medium-range 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 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 contribution 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.
    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 state-level 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.
    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 multi-year 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.

             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 government, 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 
Secretary-General 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 committee 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 
long-term 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 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, 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 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.
                              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 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 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 entertainment 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 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.
    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 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 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. 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.
    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 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 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 faith-based 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.
    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.

   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 sub-Saharan 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 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 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.
    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 process 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 
practices 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).

  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 sub-Saharan 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 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 head-on. 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:]

           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.

    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.
    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 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 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 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, 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 monitoring. 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.
    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).
                                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.
                                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.

                                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-to-child 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:

   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-of-school 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 post-partum 
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 acquisition 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 HIV-positive. 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.
    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 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-to-child 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 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 sub-Saharan 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 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 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 
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 husbands 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 sub-Saharan 
        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 number 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 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.

   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.

    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.
    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-the-art 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.
    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 prevent 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 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 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?
    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 entry-way. 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 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 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.
    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?
    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 AIDS-related. 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.
  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.
---------------------------------------------------------------------------
    \1\ Table 1 appears at end of statement.
---------------------------------------------------------------------------
    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 HIV-infected 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 dissemination 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.
---------------------------------------------------------------------------
    \2\ Chart 1 appears at end of statement.
---------------------------------------------------------------------------

      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 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 orphans 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 decade, 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 first-hand 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.

                                                        TABLE 1.--Estimated Budgetary Outlays and Needs for AIDS and All Disease Control
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                              Estimated Need by
                                                                   FY1995-1999             FY2000                FY2001                FY2002                FY2003                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)  $145 million (USAID)   $450 million (est.)   $525 million (est.)  ....................
                                                                                       +$25 m (est. CDC)     +$75 m (est. CDC)
Estimated AIDS Needs from all Donors........................  ....................  ....................  ....................  ....................         $7-10 billion         $9-12 billion
Estimated AIDS Needs from U.S...............................  ....................  ....................  ....................  ....................          $2.5 billion          $3.5 billion
U.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 billion
U.S. Contribution to Global Fund............................  ....................  ....................  ....................          $250 million          $200 million  ....................
Estimated Need for U.S. Global Fund Contribution............  ....................  ....................  ....................            $1 billion            $2 billion            $3 billion
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

                                                                                                                                                                            
                                                                                                                                                                            

    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 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 
population-based 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 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 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 community-based 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 public-private 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.
    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 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 available--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 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 
transmission\13\ 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 Brochure\19\

    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\ 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 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 unknown 
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 well-stocked 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 
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 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 
Boehringer-Ingleheim 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 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 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, Short-course (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.

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 long-term 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 commitment 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

    \1\ Watts, Sheldon, Epidemics and History, 1997, Yale University 
Press, p. 9.
    \2\ Kiple, Kenneth, ed. The Cambridge World History of Human 
Disease, Cambridge University Press 1993
    \3\ Piot P, Coll Seck AM. International Response to the HIV/AIDS 
epidemic: Planning for Success. Bulletin of the World Health 
Organization 2001;79:1106.
    \4\ Grassly 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.
    \5\ Grassly 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.
    \6\ February 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.
    \8\ World 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.
    \10\ Muller 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.
    \13\ De 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.
    \15\ Lamptey PR. Reducing heterosexual transmission of HIV in poor 
countries. BMJ 2002;424:207.
    \16\ Quinn 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.
    \19\ February 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.
    \21\ Guay 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.
    \22\ FAO 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.
    \24\ Paterson 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).
    \25\ Kim, JY ``The Role of the U.S. Congress in the HIV/AIDS 
Pandemic: Briefing to Congress'' July 20, 2001
    \26\ Kaiser Daily HIV/AIDS Report. February 5, 2001.
    \27\ Mehta S, Moore RD. Potential factors affecting adherence in 
patients with HIV therapy. AIDS 1997;11:1665-70.
    \28\ Fischl 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).
    \29\ Stenzel 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.
    \31\ Willbond 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.
    \32\ Djomond G, Roels T, Chorba T. Cote d'Ivory Ministry of 
Health--UNAIDS HIV/AIDS Drug Access Initiative--Preliminary Report 
UNAIDS. Geneva, 2000.
    \33\ Willbond 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.
    \34\ Personal Communication.
    \35\ PANOS 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.
    \37\ Data from UNICEF and WHO statistical resources.
    \38\ World Health Organization. Scaling Up the Response to 
Infectious Diseases: A Way Out of Poverty. World Health Organization. 
Geneva, 2002.
    \39\ World 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.
    \41\ Gilson L. Management and Health care reform in sub-Saharan 
Africa. Social. Science and Medicine 1995;40:695.
    \42\ Kelly 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.
    \45\ Sykes 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 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 believe 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 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.
    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 faith-based 
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 daughter, 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).

          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 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.]

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