U.S. GOVERNMENT PRINTING OFFICE

69–977 DTP WASHINGTON : 2001

HIV/AIDS IN AFRICA: STEPS TO PREVENTION

HEARING

BEFORE THE

SUBCOMMITTEE ON AFRICA

OF THE

COMMITTEE ON

INTERNATIONAL RELATIONS

HOUSE OF REPRESENTATIVES

ONE HUNDRED SIXTH CONGRESS

SECOND SESSION

SEPTEMBER 27, 2000

Serial No. 106–192

Printed for the use of the Committee on International Relations

(

Available via the World Wide Web: http://www.house.gov/international—relations

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

Internet: bookstore.gpo.gov Phone: (202) 512–1800 Fax: (202) 512–2250

Mail: Stop SSOP, Washington, DC 20402–0001

(II)

COMMITTEE ON INTERNATIONAL RELATIONS

BENJAMIN A. GILMAN, New York, Chairman

WILLIAM F. GOODLING, Pennsylvania

JAMES A. LEACH, Iowa

HENRY J. HYDE, Illinois

DOUG BEREUTER, Nebraska

CHRISTOPHER H. SMITH, New Jersey

DAN BURTON, Indiana

ELTON GALLEGLY, California

ILEANA ROS-LEHTINEN, Florida

CASS BALLENGER, North Carolina

DANA ROHRABACHER, California

DONALD A. MANZULLO, Illinois

EDWARD R. ROYCE, California

PETER T. KING, New York

STEVE CHABOT, Ohio

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

MATT SALMON, Arizona

AMO HOUGHTON, New York

TOM CAMPBELL, California

JOHN M. MCHUGH, New York

KEVIN BRADY, Texas

RICHARD BURR, North Carolina

PAUL E. GILLMOR, Ohio

GEORGE P. RADANOVICH, California

JOHN COOKSEY, Louisiana

THOMAS G. TANCREDO, Colorado

SAM GEJDENSON, Connecticut

TOM LANTOS, California

HOWARD L. BERMAN, California

GARY L. ACKERMAN, New York

ENI F.H. FALEOMAVAEGA, American

Samoa

DONALD M. PAYNE, New Jersey

ROBERT MENENDEZ, New Jersey

SHERROD BROWN, Ohio

CYNTHIA A. MCKINNEY, Georgia

ALCEE L. HASTINGS, Florida

PAT DANNER, Missouri

EARL F. HILLIARD, Alabama

BRAD SHERMAN, California

ROBERT WEXLER, Florida

STEVEN R. ROTHMAN, New Jersey

JIM DAVIS, Florida

EARL POMEROY, North Dakota

WILLIAM D. DELAHUNT, Massachusetts

GREGORY W. MEEKS, New York

BARBARA LEE, California

JOSEPH CROWLEY, New York

JOSEPH M. HOEFFEL, Pennsylvania

[VACANCY]

RICHARD J. GARON, Chief of Staff

KATHLEEN BERTELSEN MOAZED, Democratic Chief of Staff

SUBCOMMITTEE ON AFRICA

EDWARD R. ROYCE, California, Chairman

AMO HOUGHTON, New York

TOM CAMPBELL, California

STEVE CHABOT, Ohio

THOMAS G. TANCREDO, Colorado

GEORGE RADANOVICH, California

DONALD M. PAYNE, New Jersey

ALCEE L. HASTINGS, Florida

GREGORY W. MEEKS, New York

BARBARA LEE, California

TOM SHEEHY, Subcommittee Staff Director

CHARISSE GLASSMAN, Democratic Professional Staff Member

MALIK M. CHAKA, Professional Staff Member

COURTNEY ALEXANDER, Staff Associate

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C O N T E N T S

Page

WITNESSES

Vivian Lowery Derryck, Assistant Administrator, Bureau for Africa, USAID ... 3

Sanford J. Ungar, Director, Voice of America ....................................................... 6

Dr. Peter Lamptey, Senior Vice President, Family Health International .......... 20

Mary Crewe, Director, HIV–AIDS Unit, University of Pretoria .......................... 22

APPENDIX

Prepared statements:

The Honorable Edward Royce, a Representative in Congress from the State

of California, and Chairman, Subcommittee on Africa ..................................... 33

The Honorable Don Payne, a Representative in Congress from the State

of New Jersey ....................................................................................................... 34

Vivian Lowery Derryck ........................................................................................... 36

Sanford Ungar .......................................................................................................... 46

Peter Lamptey .......................................................................................................... 53

Mary Crewe .............................................................................................................. 60

Additional material:

Representative Barbara Lee: Durban Report, ‘‘Summary of Findings: Overview of HIV/AIDS in Sub-Saharan Africa’’ ........................................................ 63

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HIV/AIDS IN AFRICA: STEPS TO PREVENTION

WEDNESDAY, SEPTEMBER 27, 2000

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON AFRICA,

COMMITTEE ON INTERNATIONAL RELATIONS,

Washington, DC.

The Subcommittee met, pursuant to call, at 2:20 p.m. in Room

2172, Rayburn House Office Building, Hon. Ed Royce [Chairman of

the Subcommittee] presiding.

Mr. ROYCE. This hearing of the Subcommittee on Africa will

come to order. Today, the Africa Subcommittee will look at HIV/

AIDS, the pandemic in Africa. Particularly we will look at steps

that can be taken to prevent its spread. The HIV/AIDS crisis has

taken a devastating toll on Africa. An estimated 16 million Africans have died from HIV/AIDS. Two-thirds of the HIV-infected people worldwide, that is some 30 million people, are in sub-Saharan

Africa. It is estimated that over the next 20 years AIDS will claim

more lives than all the lives of the wars in the 20th century. HIV/

AIDS is damaging to Africa’s economic development. It absorbs

sparse resources. It strikes down people in their prime of life. It destroys social cohesion. The AIDS epidemic is having an alarming

impact on children in Africa. AIDS orphans run a greater risk of

being malnourished or of being abused and, of course, being denied

any education, and because of women’s lack of economic and social

power, Africa is the only region in the world in which women are

infected with HIV at a rate higher than men.

AIDS is ripping apart African families while harming political

stability and harming democratic development in Africa.

As the Namibian Secretary of Health has written, prevention is

the only weapon that will effectively halt the HIV/AIDS epidemic.

There is no doubt prevention efforts must overcome significant cultural, educational and resource challenges, but the battle can be

won. Progress demands a political commitment on the continent.

President Yoweri Museveni of Uganda has raised the issue of AIDS

in virtually every speech he has ever given in public since 1986.

With this commitment, including support for anti-AIDS village education projects that I have witnessed, Uganda has made impressive

strides in reducing its HIV infection rate.

Part of Uganda’s success can be attributed to the support of its

relatively vibrant civil society backed by private sector entrepreneurs.

By contrast, President Robert Mugabe of Zimbabwe has barely

uttered a word about AIDS in his 20 years in power. AIDS is devastating Zimbabwe.

2

There is no question that the U.S. should be doing more to address the AIDS crisis in Africa. This means committing more resources, and I want to commend my colleague Barbara Lee of the

Subcommittee for the work she has done in this regard.

I also wanted to share with you that we are videoconferencing

with one of our witnesses today in South Africa, and we are Web

casting so that people from anywhere in the world can look in and

follow this dialogue and hear this debate, and I would just like to

share the way to do that and that is www.house.gov/internationallrelations, and that will allow you to pick up the Web

site.

At this time, I would like to turn to my colleague Congresswoman Barbara Lee, to ask her if she would like to make an opening statement before we go to our first panel.

[The prepared statement of Mr. Royce appears in the appendix.]

Ms. LEE. Thank you, Mr. Chairman. I want to thank you for conducting this hearing and for once again focusing our attention with

regard to the pandemic of HIV/AIDS in Africa. Today’s hearing is

another example of the attention that the AIDS crisis is gaining in

the Congress and we are forcing the idea that Africa truly does

matter.

I would also like to thank all of our hearing participants for joining us today and for offering their testimony to help us focus our

efforts to learn how to prevent HIV/AIDS. It is also extremely important to note that the global AIDS crisis also forces us to reevaluate our public health policy by including more profound steps to

bring a balance between prevention and education and treatment

and care. HIV/AIDS continues to wreak havoc in Africa but once

again, as we have said so many times, Africa is unfortunately the

epicenter of this disease.

The World Health Organization has proclaimed that HIV/AIDS

is the world’s deadliest disease. We see now India and Southeast

Asia and Eastern Europe and other parts of the world becoming

victimized by this deadly disease. Yet in a Washington Post article

it was revealed that while our intelligence agencies and our government knew about this as early as the 1990’s, we really didn’t do

much. We chose to sit on our hands. So now the survival of a continent is at stake. So we must continue to beef up our attention to

put more resources into this pandemic.

In July, I was privileged to have traveled to the International

AIDS Conference in Durban, South Africa, and the thing at that

conference was breaking the silence. For many of the participants

at that conference it also served as a message of hope, breaking the

despair.

These hearings, Mr. Chairman, really do allow us to continue to

break the silence here in Washington, DC.

I have a report from my visit to the Durban Conference and it

would be available for anyone who would like to look at what we

concluded and found.

Mr. ROYCE. And we will put that into the record.

Ms. LEE. Thank you, Mr. Chairman.

Mr. ROYCE. Without objection.

[The information referred to appears in the appendix.]

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Ms. LEE. With that, I will stop now and look forward to the participants here today and want to thank you again for this.

Mr. ROYCE. Thank you, Congresswoman.

Our first panel—we have just been joined by the Vice Chairman

of the Subcommittee, Amo Houghton—we will now go directly to

our first panel.

Miss Vivian Lowery Derryck has been the Assistant Administrator for Africa with the U.S. Agency for International Development since July 1998. Prior to joining AID, she was Senior VicePresident and Director of Public Policy at the Academy for Educational Development, a U.S.-based private voluntary organization.

Ms. Derryck has worked in more than 25 countries, in Africa,

Asia, South America and the Caribbean, including 4 years teaching

at the University of Liberia. She has also served as a Deputy Assistant Secretary of State.

Mr. Sanford Ungar has been the Director of the Voice of America

since June 1999, overseeing 900 hours a week of VOA broadcasts

in English and 52 other languages which reach 91 million people

around the world.

Prior to joining the VOA, Mr. Ungar was the Dean of the American University School of Communications for 13 years.

Mr. Ungar has had a distinguished career as a print and broadcast journalist, including a stint as the Nairobi correspondent for

Newsweek. He has written a number of books, including Africa:

The People and Politics of an Emerging Continent. VOA and Radio

Free Asia, I might add, are very important foreign policy tools.

Ms. Derryck, if you would commence, and since we have your

written testimony, we would ask you both to just summarize your

testimonies within the scope of 5 minutes. Thank you.

STATEMENT OF VIVIAN LOWERY DERRYCK USAID—ASSISTANT

ADMINISTRATOR, AFRICA BUREAU

Ms. DERRYCK. Thank you very much, Mr. Chairman, and thank

you for holding this hearing. HIV/AIDS is one of the gravest

threats to the global community and certainly it is the development

challenge for Africa.

In this oral testimony I will focus on prevention because my remarks have been summarized for the record, but I do want to make

a few observations before getting to prevention. First of all, just to

underscore the fact that HIV/AIDS is a long-term issue, and we are

going to have this problem with us for many, many years, as the

number of those infected and the number of deaths indicate; and

plus the fact that there is no vaccine in sight.

Secondly, HIV/AIDS affects absolutely every aspect of a developing country from GDP to education and, therefore, for us at

USAID it requires multisectorial responses. Thirdly, responses to

the pandemic have to be regional because the disease knows no

boundaries. So we cannot work in Swaziland and not work in Lesotho. We can’t work in South Africa and not work in Botswana. So

for us, it is important as well that we have a regional approach.

Fourth, as you said, Mr. Chairman, the disease differentially impacts women, but for us this is a major, major area of concern because about 55 percent of all new infections in Africa occur among

women, and the vulnerability of the disease is especially high

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among young girls because they have the lack of education, inadequate access to information and other generally lower economic

and social status.

Lastly, the only hope that we have at the moment to stem the

scourge is prevention, and that is going to be the focus of my remarks. I, too, was in South Africa for the Durban Conference with

Congresswoman Lee, and the bulk of my remarks will be based on

my observations there.

We know that we need to really focus on prevention and behavioral change. We know that preventing infections and thereby protecting the 70 to 80 percent of the population that is not yet infected should be our highest priority. And it is important to remember that, that the proportion of the populations that are not yet infected is very, very high. It is as high as 95 to 99 percent in a number of West African countries and our effort should be to make sure

that those numbers remain just where they are.

Successful prevention programs incorporate a set of interventions, and there are about five of them. Better availability of information, condoms and social marketing, mother to child transmission prevention, voluntary counseling and testing and access to

support services for persons that are infected.

All this means that we have to have broad multisectorial approaches to the epidemic.

But prevention requires behavioral changes, and one change that

we have advocated is increased use of condoms, and in Africa we

see that this is really making a difference. So that is one prevention area.

Our social marketing programs have been increasingly effective

over the past years and sales have really soared. On the whole,

more men report using condoms than women and both sexes are

more likely to use condoms for sex with casual partners. But female condoms are an added measure that women can undertake to

protect themselves. Female condoms aren’t meant to replace male

condoms but rather their availability increases the options available to women to protect themselves.

I just underscored the point that I made earlier about the need

to really think about women and ways to protect them because

they are differentially impacted. USAID is also very much involved

in a second preventive strategy, and this is one that we highlighted

a lot at Durban, and that is voluntary counseling and testing.

UNAIDS estimates that 90% to 95% of Africans don’t know their

HIV status. The availability of voluntary counseling and testing

will increase access to information and services that will inform Africans of their status, whether they are sero-positive or sero-negative. I talk about VCT as faster, quicker, cheaper. It is faster because it is just a finger prick. It is quicker because you find out

your status in 45 minutes rather than having to come back in 10

or 12 days, and it is cheaper at $1 to $2 per kit, and with the surround of counseling the cost is about $12 to $24 per person and

that is a dramatic decrease, and we think that that is really very,

very promising.

Another intervention that we are focused on is MTCT, trying to

reduce mother to child transmissions. That is responsible for 10

percent of all new infections in Africa. Because multiple factors inVerDate 11-MAY-2000 14:42 Apr 02, 2001 Jkt 069977 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 F:\WORK\AFRICA\H092700\69977 HINTREL1 PsN: HINTREL1
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fluence transmission of HIV from parent to child, USAID is supporting a broad set of interventions to prevent MTCT, but we think

that carefully implementing these programs has the potential of

not only saving the lives of infants but also serving as a catalyst

for improving and expanding HIV prevention and care services.

MTCT is really a very complex intervention to deliver. We are

trying to support a set of interventions that include training of

health workers, providing the VCT services so that the mothers

know their status; providing the drugs in some cases and developing community-based support systems for women and their children.

We are trying to work in a situation in which we can reduce the

stigma and that is really one of the complexities of MTCT, because

in many communities breast feeding is the norm and to be seen

giving breast milk substitutes or formula discloses one’s status and

brings a whole set of social issues. We know what happened in the

case of disclosing status with Gugi Dlamini in South Africa, which

was featured at the Durban conference.

Mr. Chairman, I mentioned that this is a long-term problem and

nothing better illustrates that than the demographics on orphans,

and that was the second major finding that occurred for us from

Durban. This epidemic is producing orphans on a scale that is

unrivaled in world history.

Forty million children are estimated to become orphans by 2010

from all causes, but new statistics indicate that that number might

go up to 44 million children, and the overwhelming majority of

them are going to be in Africa. And these children are pressed into

service for their ill and dying parents. They have to leave school.

They have to help out in the household. Many of these girls are

pressured into sex to help pay for the necessities for their families,

and this is a major, major problem.

We visited a place, Kato Housing in Durban, and lo and behold,

we were told that when they were doing surveys that they knocked

on one door and they found that a 10-year-old was responsible, he

was the adult, he was the household leader, and so we have seen

this over and over again, and we at USAID think this is something

that we have to work on. We call this the iceberg phenomenon.

We are developing a set of community-based responses to support

orphans, and the USAID publication, Children at the Brink, which

is really a seminal work, identifies five basic strategies that we will

use. I am just going to mention three of them. We are going to

strengthen the capacity of families to cope with these problems of

orphans. We are going to mobilize and strengthen communitybased responses, and we are going to work to ensure that governments protect the most vulnerable children.

We believe that the first line of defense is to enable children to

be able to stay in school. Ultimately education is the key to this,

so that they can acquire the skills to care for themselves and to be

able to be effective, carriers of the creed that one should not engage

in unprotected sex.

So in conclusion, Mr. Chairman, we believe that we at USAID

have led the fight in this epidemic; we know we have since 1986.

We are the largest bilateral donor for HIV/AIDS. We have technical

expertise across the continent that is really unmatched.

6

In the past 2 years, we have increased our investment to fight

this problem. The Leadership and Investment in Fighting an Epidemic, the LIFE initiative, which has been launched by the Clinton

administration and handsomely supported by Congress, is a very

strong acknowledgment of the pandemic and last year reflected a

package of interventions that have been shown to work.

Since 1986, we have learned several lessons. One is the knowledge that you have to fight the epidemic through the involvement

of senior leadership. Mr. Chairman, you mentioned President

Museveni as a good example of that and hopefully we will see more

and more African leaders coming to the fore. We have also learned

that we can’t just rely on one or two interventions to turn around

the kind of epidemics that we see raging in Africa. I focused on the

ones that we hope will work but we have got to focus on prevention, behavioral change, home-based care and treatment, and care

for orphans and building infrastructure.

We will work with other donors to increase and coordinate support and encourage and reinforce national attention and leadership

such as in Uganda and Senegal, and USAID will address this special challenge of orphans.

I thank you.

[The prepared statement of Ms. Derryck appears in the appendix.]

Mr. ROYCE. We thank you, Ms. Derryck, very much. We will go

now to Mr. Ungar’s testimony.

STATEMENT OF SANFORD UNGAR, DIRECTOR, VOICE OF

AMERICA

Mr. UNGAR. Thank you, Mr. Chairman. Thank you to your Subcommittee and its excellent, efficient and thoughtful staff for arranging this hearing today.

I have been asked to speak about the role the media are playing

in preventing and containing the spread of HIV/AIDS in Africa. We

have taken a special interest in this issue at the Voice of America,

as you know, given that an estimated 40 percent of our listeners

now live in Africa, and I might say, Mr. Chairman, we have been

very grateful for your support and for your participation in programs and conferences that we have held recently at VOA.

Confronted by the stark statistics and dire forecasts associated

with most discussions of HIV/AIDS in Africa, one could easily be

overwhelmed by the scope of this pandemic. Open discussion of

HIV/AIDS, a frank explanation of the methods of prevention and

treatment and the encouragement of social acceptance for individuals afflicted with the virus are all critical.

So is the exposure of bogus explanations for the disease’s origin

and of get-rich-quick quack schemes that hold out false promises

of a cure. The media working in Africa have a responsibility to convey accurate information to people who may be at risk of contracting the virus, but local media in Africa are not always operating on a level playing field, particularly when it comes to coverage of HIV/AIDS. They often find themselves subject to censorship by governments still coming to terms with the scope of the

virus and the catastrophic consequences it portends for their countries.

7

In the absence of unambiguous authoritative statements by some

African leaders to break the silence and stigmatization associated

with HIV/AIDS, popular misperceptions about transmission and

treatment have been allowed to flourish; thus, making the media’s

role much more difficult to accomplish and that is why outsiders

must help.

In Africa, if I may say so, radio is king, and it is often the most

effective means of reaching people and generating discussion of

subjects long considered taboo. At its best, radio in Africa can serve

as an antidote to the dearth of reliable medical information about

how HIV/AIDS is spread and how it can be prevented and treated.

This must be done, even at the risk of intruding, violating the old

code of silence or offending sensibilities.

I would like to describe for you a few of the ways that the Voice

of America and some of its affiliate stations in Africa are working

on this problem. VOA broadcasts into African homes in 11 languages every day. Let me repeat that. We broadcast into Africa in

11 languages every day. And over the past 15 years, we have made

stories about HIV/AIDS a broadcasting priority. Our features on

the topic have tried to help some 36 million listeners in Africa

make informed choices about dealing with the disease.

VOA’s programs on HIV/AIDS are not limited by any means to

shortwave radio or even to medium wave or FM. The Internet and

television amplify the impact and the reach of these broadcasts. Already, VOA streams nearly 70 hours of live or on-demand programs to Africa on the Internet each week. In urban areas throughout the continent, where television has begun to rival radio in popularity, VOA affiliate stations broadcast Africa Journal, a popular

weekly call-in television program which has tackled HIV/AIDS related issues from many angles ever since going on the air 9 years

ago. It has created the kind of space for open dialogue about HIV/

AIDS that may be difficult for many African viewers to find in

their own communities.

A new VOA weekly radio-television simulcast called Straight

Talk Africa has just been launched and will also treat HIV/AIDS

in upcoming programs. For those programs and others, including

this week an English language TV news-magazine shown by several African networks and individual stations, VOA video journalists with digital cameras have learned to enhance HIV/AIDS-related stories with powerful images.

The effectiveness of information is often difficult to measure, as

you know, but there are some telling signs that we have had an

impact. Earlier this year, the director of Rwanda’s national antiAIDS program cited VOA Central African service for its help in

raising awareness among his countrymen about the impact of HIV/

AIDS on their society.

He noted that the number of Rwandans who now admit to carrying the disease has increased.

Last year, VOA joined forces with the Confederation of East and

Central African Football Associations and the Johns Hopkins University Center for Communication Programs to develop a series of

HIV/AIDS-related messages, public service announcements, that

were recorded by soccer players and broadcast during an African

soccer tournament. In addition to earning VOA an award from that

8

football confederation, it promoted several African sports reporters

to team up to form the Association of Sports Journalists for Health

in East and Central Africa. Now funded in part by a grant from

Cable Positive and HIV/AIDS Awareness Foundation associated

with the American cable television industry, VOA is about to embark on ambitious and innovative HIV/AIDS programming for

southern Africa. Working especially with two of our affiliate stations, Bush Radio in Cape Town, South Africa, and Radio Pax in

Beira, Mozambique. We will produce HIV/AIDS awareness concerts

commemorating World AIDS Day in December.

Leading up to the concerts will be a series of teen town meetings

with youth in Cape Town area high schools and a community-wide

townhall meeting in Barea about HIV/AIDS-related issues. I am

very pleased to be able to say that we just had word today that

BET, Black Entertainment Television, will be joining us as a sponsor and participant in these concerts and our other efforts in this

HIV/AIDS awareness program in southern Africa.

At the same time, VOA will create a radio documentary miniseries in English and Portuguese identifying certain communities

in southern Africa and even particular individuals to follow over

the next 2 years in order to understand better the impact of HIV/

AIDS in the region.

Community members themselves will give personal accounts to

listeners across Africa of how HIV/AIDS has affected their own

lives. Broadcasting from Washington, we recognize that our reach

is limited and thus we rely particularly on our affiliate stations in

Africa to carry our broadcasts on local FM frequencies.

From a media perspective, they are on the frontlines in the battle

to contain and prevent the spread of HIV/AIDS, and their efforts

to educate their listeners truly inspire our admiration.

Some might ask, what business is it of Voice of America to become involved in the enormous, often frustrating task, of fighting

AIDS in Africa? My answer is that this kind of health reporting is

in the best public service tradition of American journalism. Just as

VOA has had an effective role to play in the worldwide effort to

eradicate polio, working alongside Rotary International, the World

Health Organization and the U.S. Agency for International Development, it is now joining forces with others to confront HIV/AIDS.

Even if this is not our first line of work, it is entirely appropriate

for a news organization like VOA to form partnerships with other

journalists and government agencies to leverage each other’s contributions in the fight against HIV/AIDS, especially where opportunities exist to reach directly the ears of statesmen and policymakers.

To conclude, by now few people doubt the importance to international security of the effort to deal with this disease. As we have

reported on the Voice of America, there is a daunting worldwide

recognition of the social, economic, political and even strategic

threat posed by HIV/AIDS, once viewed as a medical issue of narrow importance. But let me make an obvious point. No amount of

international support will result in a reduction in the rates of HIV

infection across Africa if there is not outspoken indigenous African

leadership on the issue and a broader view of the problem. Local

media and international broadcasters like VOA have the potential

9

to create open spaces for a dialogue about how to prevent and contain HIV/AIDS, but without the bold support of respected national

and community leaders in Africa in bringing this conversation closer to home, all efforts to halt the advance of this killer virus will

be doomed to failure.

Thank you very much.

[The prepared statement of Mr. Ungar appears in the appendix.]

Mr. ROYCE. I thank you, Mr. Ungar.

Ms. Derryck, in the closing comments that Mr. Ungar was making, he was speaking to the fact that we need outspoken indigenous

support from African leaders. You cited and I previously cited the

situation in Uganda where a very aggressive and successful attack

on AIDS through prevention seems to have prevailed, so much so

that an AIDS rate that had been 30 percent, I think, in 1992 was

10 percent by 1998 in terms of infection rate. What are the key lessons that we can learn from Uganda? Is there something unique

about Uganda that shaped their particular strategy?

Ms. DERRYCK. Thank you, Mr. Chairman. I certainly do agree

with both you and Mr. Ungar that Uganda is a good example.

One of the keys is the leadership and the involvement not only

of the President but of others in his Cabinet. We were talking the

other day about infrastructures and whether the Ugandan infrastructure is any better than others in Africa, and there was a

mixed opinion on that but there certainly are government resources

that are used to maintain that infrastructure. So that is important.

And another point would be that the government puts its own

money into fighting the disease as opposed to relying simply on donors.

I think also the emphasis on education is important. Uganda

makes a major investment in girls’ education and that, of course,

helps to prevent further infections as well.

And then lastly, the fact that they have been able to eliminate

the stigma, because in so many countries when you declare your

status then you become stigmatized and ostracized, and in Uganda

that has not happened. In fact, there are so many NGOs, TASO

and others, that work proactively to make sure that there is a caring support system available, it really does make a difference. So

I think that all of those things help to contribute to their success.

Mr. ROYCE. I think that in Uganda, in the health centers, in the

schools, pamphlets are readily available in terms of the deep stigmatization; you have situations where young ambassadors who go

to different schools to talk to young people about this problem are

made up half of children that are HIV-negative, half HIV-positive

but without disclosing they share their stories. They do seem to do

this in a way that conveys the information without creating in the

society resistance to it, and it has had a remarkable effect on the

decrease of the rate.

One of the questions that I have is what the U.S. Department

of Defense is doing in terms of trying to work with African militaries to combat AIDS because we hear that that is a large part

of the problem with HIV infection among the armed services. What

exactly is the DOD doing in Africa and are any African militaries

being utilized to combat AIDS in their specific societies?

10

Ms. DERRYCK. Mr. Chairman, we are very concerned about the

role of the military because, for instance, in West Africa the

ECOMOG (Economic Community of West African States Monitoring Group) troops from Nigeria and Sierra Leone and earlier in

Liberia really are vulnerable to the disease and militaries are a

vector of the disease.

We have special waivers now within USAID that will allow us

to work with African militaries, and we have one program that is

beginning in Nigeria. We have talked about the fact that testing

would be a very good first step, and with the new cheaper VCT

that I talked about, then that is one possibility, but AID will plan

to work closely with DOD because it is a natural collaboration for

a problem that really does span the entire continent.

Mr. ROYCE. Thank you. I wanted to ask Mr. Ungar a question,

too, about which African governments are the greatest offenders in

terms of censoring independent broadcasting. What I wanted to

know was, are HIV and AIDS prevention messages ever blocked by

governments or do they take a laissez-faire attitude and allow the

broadcasts?

Mr. UNGAR. Well, Mr. Chairman, of course, we attempt not to be

censored by any governments in Africa or anyplace else in the

world, and the programs that we send in to Africa are going by

shortwave, by medium wave, by FM through affiliates and now increasingly by television and the Internet as well.

I would say that there are some countries that are known to

have suppressed local media coverage of HIV/AIDS. Zimbabwe

would be one that I am sure you are familiar with. This has been

rather taboo to be spoken of in Zimbabwe over recent periods.

There is a remarkable parallel between the countries who have

made progress and those in which there has been open discussion

in the media.

For example, in Uganda, the discussion has been more open in

the local media. In Senegal, that is certainly the case as well. Senegal has been a leader in West Africa. I think increasingly in Nigeria these issues are openly being discussed. The media have become freer with the return of civilian rule, as you know. We are

particularly concerned that the VOA programs, the countries that

would have the greatest impact in Africa, that these issues be

treated. I would say that we have made a particular effort in all

of our 11 languages that are going to Africa, but especially Hausa

in Nigeria, Hausa and English in Nigeria, and then, of course, our

Horn of Africa service, including our inherent broadcasts where our

largest listenerships in Africa are in Nigeria and Ethiopia, and we

have been treating these issues with particular care there.

Mr. ROYCE. I thank you very much. I want to go to my colleague,

Barbara Lee of California, for her questions at this time. Let me

say she has been a leader on this issue in the House of Representatives. Barbara.

Ms. LEE. Thank you, Mr. Chairman.

Let me thank you both for your presentations today. I want to,

Ms. Derryck, state to you that I think given the minimal resources

that you have that you are doing a fantastic job, at least in helping

to begin to respond to this pandemic, and we are going to have to

11

figure out how to make sure that additional funding is available for

the work that you do.

I was in Nigeria last year, it was actually on World AIDS Day,

with Mr. Gejdenson and also very recently with President Clinton

on his visit to Nigeria and to Tanzania. One of the issues that came

up and that I read about and had discussions about had to do with

the issue of blood transfusions and infections, the high rate of infections as a result of blood transfusions. I have talked to several

officials over at USAID. I think I have talked briefly with yourself,

Ms. Derryck, and I want to follow up and just find out if, in fact,

we have the statistics with regard to the most infected countries,

but especially with Nigeria. We heard maybe 10 percent of the 5

percent of the infections were as a result of blood transfusions. But

even if it is 2 percent in a country such as Nigeria, that is an enormous amount of pain and suffering that doesn’t have to exist, because we know how to deal with blood banks and blood transfusions.

So can you give us some feedback on that, what we know about

that and what we are doing, if anything, to help African countries

deal with that, deal with blood transfusion issues?

Ms. DERRYCK. Thank you, Congresswoman.

The whole issue of blood transfusions does come up frequently.

I do not know an awful lot about the issue because I think it is

something that we work with CDC on, and I will have to get back

to you on the specifics of this. But let me just say a word about

infrastructure, because we think about that a lot in terms of dealing with the pandemic. And the whole issue of blood transfusions

and maintaining the purity of those transfusions I think really is

compromised by imperfect infrastructures that we see all over the

continent. It goes from the potable water to the lack of trained

technicians, to the inability to carefully and systematically monitor

blood transfusions. We see it basically throughout health care systems and other infrastructure, but certainly for health care systems

in terms of HIV/AIDS.

But on the specifics, we will have to get back to you.

Ms. LEE. Thank you very much. Let me also just ask with regard

to the programs in Uganda and Senegal, which I believe are the

models, the examples for effective prevention and treatment, have

they had the issue of blood transfusions to deal with? And then secondly, what is it about their approach and their strategies that

have allowed them to be the model countries that have been able

to get this under control?

Ms. DERRYCK. Let me just ask my colleague about Uganda and

the blood transfusions.

My colleague says that the European Union has been involved

over the long-term, and early on we were supporting some blood

transfusions as well.

Ms. LEE. And what are the elements of both countries’ strategies

that could be adaptable in other countries that they really need to

know that we maybe could support?

Ms. DERRYCK. First of all, it is that whole question of leadership

and it is not only President Museveni but it is Mrs. Museveni as

well, and when we start talking about stigma and women, that becomes an important component of what has happened in Uganda.

12

It is also the question of their investing their own resources in

the fight of this. They have enlisted even leading entertainers in

songs who have performed on this. They also have made a serious

investment in nongovernmental organizations, and those NGOs

spread the word and make sure that they have a very strong network that is supportive of people in the country.

Uganda has been fighting this for so long, but we have had more

than a decade of experience with this. So, therefore, there is a culture now of accepting the disease and culture of confronting the

issue, and so that helps as well.

Senegal has been very successful in maintaining a low prevalence because they too have had a major investment in research.

Senegal has also worked very successfully with prostitutes and

prostitutes who follow the military, and so they have been able to

again publicize the fact of prevention and of safe sex. So that has

been a major element of their success. But in both countries it is

the investment of their own resources and in senior leadership and

it is, as you said, breaking the silence, breaking the stigma of the

disease.

Ms. LEE. In a perfect world, what dollar amount of money should

we be looking at as a U.S. contribution?

Ms. DERRYCK. Oh, I am so glad that you asked me that. Thank

you. To halt the epidemic, we think that we need $1.2 billion to $2 billion. That is just for prevention per year in Africa. We need $3

to $4.9 billion for prevention and care. But those amounts exclude

the infrastructure improvements that are necessary long-term.

Ms. LEE. What is our budget now?

Ms. DERRYCK. For Africa, it is $114 million for 2000 and the request is $139 million for 2001. So that is clearly not a very significant amount to begin to deal with this.

Ms. LEE. Why didn’t you request $1.3 billion?

Ms. DERRYCK. I would have to defer to the Administrator and to

our own colleagues on that one.

Ms. LEE. Thank you.

Mr. ROYCE. Thank you, Congresswoman. We will now go to Congressman Greg Meeks of New York.

Mr. MEEKS. Thank you, Mr. Chairman. Let me just ask, just

picking up right where my colleague Barbara Lee left off, some— you know, you talk about infrastructure. Some have argued that

the underlying problem with HIV is the poverty that is in various

countries or on the continent. To what degree is that true and do

you think that we have to wipe out the poverty that is going on

on the continent before we can really get to the HIV/AIDS problem?

Ms. DERRYCK. Thank you, Congressman, because this really is an

issue for all of us who work in development. In the Africa Bureau,

we say that our major goal, our major priority for all of our activities, is poverty alleviation. To get at poverty alleviation, you have

to deal with education and you have to deal with increasing incomes; you have to deal with issues of nutrition, family planning

and health.

There in that nexus of problems we see certainly an inability to

respond to HIV/AIDS. When we begin to talk about anti-retroviral

13

drugs in Africa, I am reminded of the very graphic demonstration

that my colleague gave. People said that we just want to see what

these anti-retrovirals look like. So he went and got them out of a

refrigerator, which most people do not have. He noted that you

have to take them at a certain time, but people did not have clocks

or watches, or a constant electricity even if they had the clock, and

you need to have potable water. So just those three things demonstrated that maybe this is not the best solution to the problem,

but it gets back to poverty and to the lack of infrastructure and

sometimes back to just the basic adequate nutrition and diet. So

they are all really interrelated, but I don’t think that we can wait

to solve the poverty problem, which is really long-term, before we

have a massive attack on HIV/AIDS.

Mr. MEEKS. Well, given that, we know that some major manufacturers, major pharmaceutical manufacturers, have indicated they

are going to reduce the costs or the charge for the retroviral drugs.

Do you see any of the African nations being able to take advantage

of that? Have they been taking advantage of it, and is that going

to help, given still, even with the structural problems of not having

refrigeration, electricity, et cetera?

Ms. DERRYCK. We welcome that kind of a contribution and we

plan to—I guess all U.S. Government agencies plan to work as

closely as we can with them. I am pretty sure that we will probably

have to begin small and look at some possible demonstration programs, but they have to be in places where there is at least the

potable water and the basic infrastructure that can accommodate

those kinds of interventions.

We also have to make sure that the anti-retrovirals will be available long-term because the epidemic is long-term and so we are

going to need the resources and the material over at least the next

decade.

Mr. MEEKS. Well, I was recently in Ghana and they were talking

about there, even with the reduced charges which, you know, they

admit it was substantially cut but even with the smaller costs they

could not afford it on a large-scale basis. Has there been anything

that we have done or looked at with reference to maybe generic

drugs and the distribution of the generic drugs that could further

reduce the costs on the continent, the manufacturing of the drug

somewhere on the continent?

Ms. DERRYCK. Again, I am not really aware of those kinds of efforts, and I would have to check with my colleagues and get back

to you on that. I can tell you a little bit about it, that Nevirapine

and the fact that it now is a very cheap drug that can be used for

MTCT, and that it is certainly being used in Uganda and in some

other countries.

Mr. MEEKS. I know we talked about the dollar amount. I don’t

know whether your agency or others—I mean, I happen to have

seen when we were in Ghana on the ground there a company that

was manufacturing and producing a generic brand of drug there,

and I was wondering whether or not that is something that you or

USAID have invested in or something that you would be interested

in looking at?

Ms. DERRYCK. As far as I know—again, I will have to check this.

As far as I know, we have not invested in this and it would be

14

something that I am sure that we would be certainly willing to discuss in conjunction with other agencies, especially if we get a plusup for this because we need to look at multiple efforts to begin to

deal with this problem.

Mr. MEEKS. Let me just have two more quick questions. We

talked about Uganda and Senegal and their programs. We also

have a program in Brazil and that program distributes antiretrovirals in HIV programs. To what degree can we use Brazil as

a model that we could emulate and copy on the continent of Africa?

Ms. DERRYCK. The Brazil program seems to have had some considerable success in prolonging lives, but I think we have to look

at the prevalence rate there. Brazil has a health care system that

is much more advanced than those that we see in African countries. Brazil has the eighth largest economy in the world, and while

it has these real pockets of poverty it is, as you know, far more able

in terms of infrastructure to support this kind of long-term investment. They also are a richer country than almost any of the African countries that we are talking about.

But I don’t know. For Africa, because the prevalence rate is high

and because the resources are so limited, we think that we really

do need to focus on prevention and to put the resources that we

have in a major way toward prevention as opposed to providing the

anti-retrovirals as they have in Brazil.

Mr. MEEKS. Thank you, Mr. Chairman.

Mr. ROYCE. We will go to Congressman Tom Tancredo from Colorado.

Mr. TANCREDO. Thank you, Mr. Chairman. I have a couple of

questions for actually both of you, I think, starting with Ms.

Derryck. There are certain anomalies that present themselves

when you look at the development of AIDS on the continent of Africa, one being the fact that although research has shown that better

educated people are more likely to use condoms, but that especially

in southern Africa the teaching and the nursing professions have

been especially hard hit, essentially decimated. For either one of

you, really, how would you explain this phenomenon or what I

would call an anomaly?

Ms. DERRYCK. It is one of these really sad phenomena. I was

talking to Sandy Thurman about this the other day, not about this

but about the importance of education.

Mr. TANCREDO. I know you mentioned it in your testimony.

Ms. DERRYCK. It is that people should be more likely to change

their behaviors in ways that would help them to avoid the disease.

I was talking about in the case of Thailand, that that wasn’t necessarily true in the general educated populations. We see teachers

in southern Africa who are infected because—well, first of all because the infection rate is so much higher there. Second, that they

are desirable, socially desirable, partners and, therefore, they may

have more opportunities and they have unsafe sex. So that is one

reason, and because the infection rates in the region are so high

that makes it difficult, too.

We are losing teachers now at a rate faster than they can be replaced. This has, of course, devastating consequences for schools

and for the ability to continue to even operate classrooms in some

places.

15

There was an interesting piece in the New York Times about a

month ago that talked about the experience of teachers in rural

Cote d’Ivoire, the other side of the continent, but the fact that they

are out there, they do not have access to condoms; they are desirable partners and there are more young women there, and that

that is the nature of human beings and that is the consequence.

So it is the lack of attention. It is the lack of access to condoms.

It is the lack of attention to the messages, if they get out there,

and it is basic ignorance.

We also know that 15- to 19-year-old girls in Kenya, 80 percent

of them have no knowledge of ways to protect themselves from

HIV/AIDS. So when you have students like that and teachers who

should be more knowledgeable, then you can see that you are going

to have a recipe for a very high prevalence rate.

Mr. TANCREDO. Well, exactly. It is such a challenging aspect of

this because, of course, we want to rely upon education as the solution to not just this problem but so many, and yet it just doesn’t

seem to work. It doesn’t seem to be the place in which—or the sort

of cultural activity, societal activity, that we can rely upon in this

particular area in order to accomplish the goal. It is a very disconcerting aspect of this, I might say.

I don’t know, Mr. Ungar, do you have an observation that you

would like to share?

Mr. UNGAR. Just briefly, Congressman, more so from my prior

work at Africa than my duties now at Voice of America. I would

only add two things to what Ms. Derryck said. One is that many

teachers in Africa work away from their homes at schools, and do

not have their families near them and therefore may have multiple

partners. The other thing is that very often teachers are so poorly

paid and may become involved in other things for the sake of earning more money.

I would just note that in the programs that we are about to do,

and I can’t remember if this was before or after you came in, but

I was talking about this initiative we are making in southern Africa in English and Portuguese, and in the Cape Town area working

with our affiliate Bush Radio. In Cape Town we are going to be

having teen town meetings. We are going into the schools and that

is part of the innovative aspect of this, is not just to be sort of

broadcasting out there but to draw the schools in from the outset

in these particular programs, and we are hoping that that will

reach a greater number of teachers as well as students than our

ordinary programs might have.

Mr. TANCREDO. Along the lines then of some of the issues with

which we may be uniquely dealing, I should say, in Africa, although not entirely, but the practice of female circumcision, does

it have an effect, do you think, on the spread of AIDS and ritual

scarification? What about either or both of those two practices?

Ms. DERRYCK. Yes, but before I go to that I just want to say one

more thing about education. Realizing that education is so central

to dealing with this pandemic, we are having advisors work with

ministries of education, again this is a multisectorial approach, but

to make sure that ministries are aware of this problem certainly

of teachers, but also of making sure that there is curricular mateVerDate 11-MAY-2000 14:42 Apr 02, 2001 Jkt 069977 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 F:\WORK\AFRICA\H092700\69977 HINTREL1 PsN: HINTREL1
16

rial that deals with HIV/AIDS so we can begin at that level to try

to stem the pandemic as well.

So education is central. The teachers are one aspect of it, but the

curricular response is another one.

In terms of female circumcision, there has been some work done

on this and obviously if the knife or the implement that is used is

not clean and disinfected then one runs the risk of becoming infected. But there has also been some interesting work, and it is not

proved yet, that one of the reasons that there might be a lower infection rate in West Africa is because more young men, babies, are

circumcised. So it is an interesting little twist there, but again as

I said that has not been proved. But certainly female circumcision

is an area that can increase the spread as opposed to in any way

prevent or eliminate it.

Mr. TANCREDO. And ritual scarification?

Ms. DERRYCK. I don’t know of any evidence on that. Again, I will

have to check with my colleagues and get back on that.

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

Mr. ROYCE. Thank you, Mr. Tancredo.

Before I go to Don Payne, let me say that this will probably be

the last hearing of the Africa Subcommittee for this Congress and

I want to express all of my appreciation to all of my colleagues, especially to the Ranking Member of this Subcommittee, Congressman Don Payne. I just want to say, Don, that I have very much

enjoyed working with you over the last 2 years. I look forward to

continuing efforts to see that America is as committed to Africa as

it needs to be.

I also, Don, wanted to thank the staff here of the committee for

their important work. Don, if you would like to question our witnesses now. Thank you.

Mr. PAYNE. Thank you very much, Mr. Chairman. First of all, I

would ask unanimous consent to have my opening statement entered into the record.

Mr. ROYCE. Without objection.

Mr. PAYNE. Thank you. Secondly, along the same line, I certainly

would like to, as I have done in the past and this is really not the

mutual admiration society, he said it and I will say it now but I

have done this before so it is not new, but I would certainly like

to commend the gentleman from California, Mr. Royce, our Chairman, for the interest and dedication that he has taken on this responsibility.

I have been a Member of this Subcommittee now for 12 years

and I have served with democratic chairpersons and republican

chairpersons, and one thing that I must say is that out of all the

committees I have served on this has been about the least partisan,

but I also have to say that Mr. Royce has taken the seriousness of

his responsibilities and he was at a disadvantage coming in because he did not know as much about Africa as he did about other

parts of the world but I must say that I don’t know of anyone who

has learned more, has become more expert and has focused on the

main problems of the continent of Africa. And I have said that

when he has been present and I have said it when he hasn’t been

17

present and I would like to thank you for the work that you have

done on this committee.

Mr. ROYCE. Thank you. I appreciate it.

Mr. PAYNE. Let me ask a question or two in regard to, first of

all, I think that the fact that we are discussing HIV/AIDS in Africa

as relates to the continent is really a quantum leap forward because, you know, 4 years ago, 8 years ago, 6 years ago, 3 years ago

we could not have the level of discussion that is necessary. As we

know when things are kept in the closet, back in the change of the

century mental health was something that was kept away from

public discussion, it was something to be ashamed of, something

people didn’t want folks to know there was someone who may have

a mental problem in their families, and until we started bringing

mental health out into the open, discussing it here in the United

States, did we finally start to come up with some kind of ways to

remedy the situation. It is the same thing with HIV/AIDS in the

United States. There was a lack of discussion for it and, of course,

in particular in Africa there was even less. So I believe that one

of the first steps is recognizing that there is a problem. Up until

the present, there has been the denial that there is a problem, and

so that is a victory, a very big victory, in my opinion.

So at least now in many areas we do know that there is a recognition of a problem and at different degrees though and levels we

will see an attack on the situation.

Just 2 or 3 weeks ago I attended the Millennium Celebration in

New York and at a luncheon that was sponsored by the Corporate

Council on Africa, about 5 or 6 or 7 heads of state were present,

and some prime ministers were present, Mr. Mugabe, President

Festus from Botswana, Mozambique’s president and on and on, and

the whole theme of that luncheon was HIV/AIDS and they each

took the mike and each talked about the problem in their country

and each talked about what they were attempting to do. They varied from country to country, but as I indicated, 2 or 3 years ago

you could not get that kind of discussion out in public, in the open,

with heads of state saying we have a problem, we need help, this

is what we are doing, it is not enough.

So for that reason, I do believe that with education, with awareness, we could at least have this situation really known and therefore start to deal with it. We know that there are a lot of obstacles

to overcome.

Let me ask in relation to the legislation and let me, as I ask this

question, commend Ms. Lee and Mr. Leach for the Global AIDS

and Tuberculosis Relief Act but, Ms. Derryck, could you tell me

how the act is coming along? What steps have been taken by the

administration, unless you have already answered it, and the

World Bank to set up the AIDS trust fund foreseen in H.R. 3519?

And secondly, have donors come in? Have we donated? Have others

donated? Has there been participation? And when do you expect

the fund, if it hasn’t started operating, to begin operating?

Ms. DERRYCK. Thank you, Congressman Payne. Before I begin,

may I just join in your mutual admiration society because it has

really been a pleasure. You know, we are energized by the concern

that the both of you have shared and by your dedication and your

18

knowledge of the continent. So I think that it is a synergy that

helps us all and we are grateful to you.

I would also like to underscore the fact that there really has been

a sea change in attention among African leaders to this problem.

Last year at this time, at the ICASA (International Conference

on AIDS and STDs in Africa) meeting in Lusaka, the prime minister of Mozambique stood and talked about the need for males and

male leaders to change their minds, and that was revolutionary.

We have seen within a year’s period of time a total sea change

among African leadership. So you are right.

In terms of the trust fund, we are very supportive of it, and we

hope that there is going to be very good coordination because we

see it within USAID as a real opportunity for synergy.

Our concern is that we don’t want to see it come at the expense

of our ongoing programs. I know I am like a broken record and say

that all the time, but the pandemic is so huge that additive resources are welcome. It is going to take some time, I think, for the

Bank and Treasury and us to get together for the financing. So we

anticipate that it is likely to become operational over the course of

the next 6 or 8 months.

I am not aware yet of other countries contributing to it, and I

can just ask my colleagues if they are.

No, we do not know of any others, but I am sure that it is something that will be discussed in upcoming meetings when donors

have a chance to get together.

Mr. PAYNE. Thank you. I would hope that the administration

would push that in the future when those meetings come up.

Let me just conclude with this question. We have heard that the

fact that poverty now is certainly put in almost as the number one

problem and we have heard especially President Mbeki question

whether HIV/AIDS is in itself what it is, but that tuberculosis and

malaria and poverty in general are perhaps more of a problem than

HIV/AIDS. It does make a lot of sense that poverty—indeed, when

you have poverty and a lack of what you need, things are certainly

going to be worse, but the fact that in spite of poverty—poverty

was worse or as bad in Africa 20 years ago, 10 years ago, 5 years

ago, as it is today, but over the past 20 or 25 years we have seen

the life expectancy, in spite of this poverty, it has been there, it has

been horrible, we have seen the life expectancy, in spite of this, tuberculosis was always there, malaria was always there, cholera always got into the water, et cetera, but we have seen the average

age, life expectancy increase, actually even Botswana getting up to

the high sixties and many countries in Africa gradually increasing

each year. With the question of the HIV virus, is it everyone’s opinion that this is just one of these seven or eight medical problems

that we have in Africa or this HIV virus, which causes AIDS, is

it a new serious kind of situation that really breaks down all of the

previous gains that were made in spite of the poverty and these

diseases that have always been around?

Ms. DERRYCK. I thank you, Congressman.

When we look back over time, you are absolutely right, that the

gains in lower mortality and morbidity have been really very, very

positive until now. When you look at the new charts that the U.S.

Bureau of the Census has done and you see what is happening, the

19

inverted pyramid and these spikes in mortality in AIDS-affected

countries, you do see that this is something that is new and unprecedented.

I just want to go back to what you said about tuberculosis and

malaria because there is always this contention that malaria kills

more people than HIV/AIDS. We know now that that is not so; that

AIDS killed more people in 1999 and 2000 than malaria. So this

is something that is new. In the United States, we have been able

to deal with this because we have the infrastructure and we have

the resources, and we put a lot of money into dealing with this, and

we also have the media and other venues by which we can get people to change behaviors.

We don’t see that in Africa. So as far as any of us know, it is

something that is new. There is no cure. There is no vaccine. This

is a different kettle of fish than we have seen previously, and it

really does threaten to wipe out the development gains of the past

40 years.

Mr. PAYNE. Thank you very much.

Mr. Chairman, let me just also, as I complimented you, also

thank you very much, Ms. Derryck, for that answer, thank colleagues on the other side of the aisle. As you know, Mr. Campbell

will be leaving the House, he may be in the Senate, he may not

be. That remains—none of us know where any of us are going to

be on November 7, so we will leave that up to whatever happens,

but I would certainly like to thank Mr. Campbell for the initiatives

that he took and our many travels together, and also Mr. Amo

Houghton, who has been a long-time Africa hand and was such an

addition to the committee, and also on the other side, Mr.

Tancredo, who took his first CODEL to southern Sudan. I told him

that the only way you can take a CODEL is you have got to go to

southern Sudan first and then you can go on the other ones.

Mr. TANCREDO. And I believed him.

Mr. PAYNE. He believed me. I don’t know if there is a bigger odd

couple on every other issue in the world, but sitting around the

campfire going to our hut for the night, I don’t think there is anyone that I could be on the same page with in the middle of Sudan

than Tom Tancredo. So I would like to thank you again for traveling there with me. Thank you.

Mr. ROYCE. Thank you. I would also just like to thank Tom

Sheehy, the staff director and Malik Chaka and the other members

of the staff, including our interns that assist us here and do such

a fine job. So we thank you all.

We want to thank our witnesses, our first panel, for making the

trip down here today. We thank you so much.

We are now going to conclude our first panel and go to the second panel, so we will do that at this time.

Dr. Peter Lamptey is the Director of the Arlington, Virginia

based Implementing AIDS Prevention and Care Project, or IMPACT project as it is known. He is also the Senior Vice-President

of HIV/AIDS Programs with Family Health International, which is

an NGO with more than 12 years of experience in HIV/AIDS programming in more than 50 countries, and prior to directing IMPACT Dr. Lamptey directed the AIDS Control and Prevention

Project from 1991 to 1997, and the AIDS Technical Support Project

20

from 1987 to 1992. He was born in Ghana. Dr. Lamptey received

his medical degree from the University of Ghana. He earned a

Master’s Degree in public health from UCLA and a doctorate in the

same field from Harvard University.

Ms. Mary Crewe, with us through videoconferencing from South

Africa, is the Director of the HIV Unit at the University of Pretoria. She has been involved with HIV/AIDS work for more than

a decade. She helped to develop and manage the Johannesburg

AIDS Center, which was the largest program in the region.

Ms. Crewe is the chairperson of the National Committee for

School Based HIV/AIDS Education. She has published extensively

in the field. She is also the author of the book AIDS in South Africa: The Myth and Reality. It is good to have you with us, Mary.

Also with us is Dr. Ashraf Grimwood, Director of the National

Aids Convention of South Africa (NACOSA), with our U.S. AIDS

Mission in South Africa. It is good to have you with us as well.

Mr. ROYCE. With that said, let’s let Dr. Peter Lamptey open for

5 minutes. Again, Peter, if you could keep it brief and just a summation because we have your testimony here for the record, and

then we will go to Mary Crewe’s testimony.

STATEMENT OF PETER LAMPTEY, SENIOR VICE PRESIDENT,

FAMILY HEALTH INTERNATIONAL

Mr. LAMPTEY. Thank you, Mr. Chairman. I would like to especially thank you and this Subcommittee and all the Members of

Congress, especially Congresswoman Barbara Lee, who have all

been very supportive of the fight against the HIV/AIDS epidemic

in developing countries.

As this Subcommittee requested, my testimony today will focus

on the status of HIV/AIDS in Africa and the effective strategies for

prevention and care.

During the last 14 years, Family Health International, with support from USAID, has been involved in HIV/AIDS programs in

more than 60 developing countries. We have partnered with more

than 800 nongovernmental organizations and community-based organizations of all types. Humbly, I would suggest to you that as a

result of our experiences around the world with these NGO partners, we have an extremely broad, deep and unique perspective on

the HIV/AIDS epidemic.

African countries south of the Sahara have the worst HIV

epidemics in the world, as has been said by previous speakers.

Adults and children are becoming infected with HIV at a higher

rate than ever before. In sub-Saharan Africa with nearly 25 million

people living with HIV and 4 million new infections every year,

most of the progress achieved in the health and overall development is being reversed by this epidemic. In countries with high

adult HIV prevalence, the chances of a young, uninfected adult encountering an infected sexual partner can be as high as 40 percent.

About 50 percent of HIV infections in Africa are in women, which

also result in higher mother-to-child transmission, as has been described earlier.

Access to anti-retroviral therapy for the prevention of mother-tochild transmission is negligible in most of sub-Saharan Africa. The

children affected by HIV/AIDS constitute one of the greatest trageVerDate 11-MAY-2000 14:42 Apr 02, 2001 Jkt 069977 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 F:\WORK\AFRICA\H092700\69977 HINTREL1 PsN: HINTREL1
21

dies of this epidemic. Over 12 million children in sub-Saharan Africa have lost one or both parents to AIDS.

In our HIV prevention and care programs, we have been guided

by some key principles. These include the need to improve the capacity of implementing agencies in developing countries to implement successful HIV/AIDS programs. The second principle is to

work closely with community-based organizations. This is extremely important. Indeed, a full 90 percent of the USAID-funded

IMPACT activities are implemented by NGOs and CBOs. The third

principle is involvement of the community, especially people with

HIV and those affected by AIDS.

I will briefly mention some of the steps that we have taken for

reducing the risk of sexual transmission and preventing mother-tochild transmission. The interventions that have had the most impact in reducing sexual transmission include community-based

interventions, especially for youth and women; work-based interventions; school-based interventions, and intervention directed to

the general population through mass media and condom social

marketing. These approaches have been quite successful in a variety of countries, including Senegal, Uganda, Thailand and the Bahamas.

One of the most important interventions that bridges both prevention and care is voluntary HIV counseling and testing, which

has already been alluded to. These programs have been successful

in reducing high-risk sexual behavior, improving access to care,

and serving as an entry point for the prevention of mother-to-child

transmission.

In a program in Tanzania, VCT services led to a 37 percent reduction in high-risk behavior among those that were tested. The

use of anti-retroviral therapy to prevent mother-to-child transmission is definitely one of the most important technological advances in the prevention of HIV, but the lack of resources continues to be a major obstacle to widespread access to this intervention.

However, the most neglected area of HIV/AIDS is access to medical care and support services. Most people living with HIV/AIDS

do not have even adequate basic medical care. But, all this is affordable and feasible for people living with HIV/AIDS.

In conclusion, the HIV/AIDS epidemic continues its relentless

spread, and the response is still woefully inadequate in most countries. More than 5 million people become infected every year; yet

denial and discrimination still prevail.

However, our experiences overwhelmingly tell us that success in

HIV prevention is achievable. We need to apply the lessons learned

from successful prevention programs to other settings and expand

the coverage of these programs.

We need to double our research and be forced to find a cure, or

at least more effective and affordable therapies and a vaccine. We

know what we need to do. We know that HIV prevention can work

and care is urgently needed for those currently living with HIV/

AIDS.

Mr. Chairman, I think you will agree that there is nothing worse

than watching an innocent child or mother die a horrible death.

22

Let’s work together to save the next generation of children in subSaharan Africa and other countries from HIV/AIDS.

Thank you for inviting me to testify today.

[The prepared statement of Dr. Lamptey appears in the appendix.]

Mr. ROYCE. Thank you, Dr. Lamptey, for your testimony before

us today. We turn now to Pretoria and to Ms. Mary Crewe.

If you would give us a summation of your testimony, Mary,

thank you.

STATEMENT OF MARY CREWE, DIRECTOR OF HIV/AIDS UNIT,

UNIVERSITY OF PRETORIA

Ms. CREWE. Thank you very much. Thank you for the invitation

to be with you. I very much appreciate the opportunity to participate fully in your debate.

The crucial issues have been touched on in terms of AIDS in Africa, and that information has been transmitted to me. I have been

looking more specifically at AIDS in South Africa. As you know, we

have the fastest growing epidemic in the world. Approximately 22.4

percent of pregnant women are positive in South Africa. We know

that we have up to 1,700 new infections a day, and I think we are

at a crisis of unprecedented experience and magnitude.

I think there is a problem with the mike. Can you hear me?

Mr. ROYCE. No, you are fine, Mary Crewe. We can hear you without a problem.

Ms. CREWE. All right. What has happened in South Africa is that

there has been a strong commitment to HIV/AIDS since 1994 and

to some extent before that. We have had a general fiscal allocation

for AIDS. We have had many instances to deal with the epidemic

but there is a lack of a number of trained health care workers. We

have various ranging programs. We have a number of strategic

plans, and I think it is fair to say that in South Africa we have

a very big HIV/AIDS population, but the paradox of this is that it

has not translated into real behavior change. It has not translated

into ending this incredible stigma and prejudice that was related

to earlier, and simply it hasn’t translated into mass community mobilization to get involved through an AIDS-free country.

As has been alluded to also, I think the role of the government

recently has been somewhat controversial and the debates that

have been conducted between the government, the media and various community groups have, I think, done two things. One thing

is that they have set back the campaign around HIV/AIDS to some

extent, but I think more interestingly they have raised the profile

of HIV/AIDS to the level of emotional debate in a country which

perhaps hasn’t happened before, and there has been some awareness about the impact of AIDS on the country. I think it is crucial

that, as our president has suggested, that we do deal with the

issues around poverty but we have to look at poverty and unemployment.

South Africa still has what is classified as the fastest growing

HIV/AIDS epidemic in the world. It is estimated that 22.4 percent

of pregnant women are currently infected, with close to 1700 new

infections per day. There have been many attempts to deal with

the epidemic ranging from the life skills program in schools, to

23

training of health care workers and general AIDS-awareness campaigns.

This has created something of a paradox in that South Africa has

a very HIV/AIDS-aware population but one in which very high levels of stigma, prejudice and denial exist and the awareness has not

been translated into behavior change nor into great community mobilization to get involved and campaign for an AIDS-free country.

The role of the government has of late been controversial. The

debates that have been conducted between the government, media

and various community groups have done two things. They have

raised the profile of HIV/AIDS in the public consciousness and

have created some debate about the impact of HIV on South African development. However, the linking of AIDS to poverty as the

causal agent has caused some confusion and a reluctance to admit

that behavior change is crucial. As with previous campaigns that

have been controversial, this has served in some ways to deflect the

urgency, but for most people working in HIV and AIDS service organizations, research centers and hospitals and clinics, the belief is

that it is business as usual and that the campaigns for prevention

and care should not be affected and that the debates can give extra

impetus to their work.

AIDS workers have always had to deal with high levels of doubt

and denial, and this has allowed for a new take on how best AIDS

education should be given.

These are areas of great concern. One is the inability of communities to cope with the demands of care and support. There are few

policies which offer guidelines on crucial aspects of the transmission of HIV. We await decisions on the use of drugs in MTCT,

as well as on the controlled use of anti-retrovirals. There also needs

to be a careful decision on the provision of drugs in the absence of

a real support infrastructure. Access to drugs is a highly charged

issue, as is the question of compulsory licensing and parallel imports.

There is no formal policy on breastfeeding or on voluntary counseling and testing. There is no policy on the care for families and

particularly orphans where it is quite clear that the so-called extended families will not be able to cope with the levels of care and

support required. There is no policy on support for care givers and

no real understanding what the impact of home based care will be.

There seems to be even at a policy level an indecision and a lack

of political will.

But there is much that is happening in communities through

NGOs and CBOs. There are home based care programs, and there

is the exciting potential of the development of a home based care

kit that is likely to transform care in most communities. There are

support services, food aid as well as community education and

awareness and income generating projects. In the main these are

uncoordinated and remain inadequate for the needs of the country,

but the work that so many people is doing has not stopped because

of the current debates.

The school-based program is being expanded and there are increasing interventions aimed at youth in both school and tertiary

institutions as well as looking at ways to integrate youth not in

school.

24

The picture is very bleak at the moment, but as a discussion we

hosted on behalf of the AAI showed last week, it is by no means

hopeless, there is still time to turn the epidemic around, there is

still time to make an enormous impact in prevention and care and

still time to rethink the policies and programs, especially with regards to orphans and families and communities in distress and

most at risk.

But this requires new and creative vision, new ways of addressing the socioeconomic and political questions and a new understanding of what is possible in this epidemic and how best the society and country can hope to come through it.

Durban 2000 did energize the country and it’s important to sustain that momentum. There is a great deal of concern and this

needs to be channeled into actions that really will make a difference rather than looking at more of the same.

In conclusion, if I could just introduce the person who is on my

right, who is, in fact, not Ken Yamashita, but is Dr. Ashraf

Grimwood, who is the current chair of NACOSA (National AIDS

Convention of South Africa), and physician of enormous experience

in dealing with HIV/AIDS. Thank you.

[The prepared statement of Ms. Crewe appears in the appendix.]

Mr. ROYCE. Thank you, Mary. Thank you very much. Thank you

for your thoughts there.

Maybe I could ask you a question about the faith communities

that are active in South Africa, the Christian community, Muslim

community, Hindu communities and others there. Do they play a

role in HIV/AIDS prevention, the activities in that regard, in South

Africa?

Ms. CREWE. I think that their role could be greater. They certainly do play a role, but I think that South Africa has a very difficult problem and that problem is the perception of the situation,

or the reality of the situation, and the reality tends to get in the

way of an effective campaign. So the prevention tends to ignore the

reality, which is that we have a very high level of sexual activity

among young people and a very high level of extramarital sexual

activity, and I don’t think that the faith organizations have really

found a way to pass through that, but having said that, I think the

faith-based organizations are very strong in the provision of care

and support.

Mr. ROYCE. I see. Well, let me ask you another question that is

perplexing, and that is on neighboring Botswana, which has, I believe, the highest rate of infection, 36 percent of adults; the worst

hit country in Africa. Botswana is relatively prosperous and it has

spent very little on HIV/AIDS programs. What has gone wrong in

neighboring Botswana, in your view? Why has this situation developed there to such an extent?

Ms. CREWE. Well, what I found fascinating about Botswana is in

general denial, and that is the explanation that South Africa has

given for its epidemic, which is that you need to have high levels

of poverty, migration and internal conflict to have a high epidemic.

Botswana would seem to suggest that you don’t have to have those

requirements. I think that for Botswana, and I confess to not having studied the epidemic in Botswana terribly closely, but my sense

of Botswana is that it is a very small country, and that they believe

25

that they were particularly not at risk of the epidemic and acted,

as so many of our countries acted, too late. It is a very small country so the infection will spread very quickly, and I think it fits into

the general denial that we have across South Africa. Uganda’s response was exemplary. But I do believe that there is enormous denial, to a certain extent, of the epidemic.

So by the time your national infection rate has reached more

than 12 percent, in effect no matter what you do you are facing a

crisis.

Would you like to add to that?

Dr. GRIMWOOD. Well, I could say that the situation in Botswana

has done a turn-a-round, and I think that there is immense government leadership. There is incredible focus on what needs to be

done, and they have embarked upon several programs which would

hopefully bring about positive impact in the next few years. So the

feeling that I do get when I do travel and work in Botswana is that

things are on the right track there.

Mr. ROYCE. Another question I wanted to ask, and maybe I

should direct this at Dr. Lamptey, but it is clear that, as we have

said, some African leaders have been very aggressive in promoting

prevention. Others have not, and President Moi of Kenya faces a

situation now where 14 percent of adults, I believe, are HIV-positive. He did not endorse the use of condoms as a preventive method

until I think it was December 1999. Why was President Moi so reluctant to make this recognition? What holds back heads of state

in terms of this issue of prevention, Dr. Lamptey?

Mr. LAMPTEY. I think there are several factors, not only in the

case of President Moi but other African leaders, including President Mugabe. One of them is probably pressure of religious leaders

not to agree to the use of condoms, and in the case of Zimbabwe,

part of the reason was because they were afraid that it would increase promiscuity among adolescents. This is a belief despite of

what has been consistently shown, in studies, that the availability

of condoms does not actually increase sexual activity among adolescents.

In the case of Kenya also, I think, over the years has been the

fear that some of these efforts will affect the tourist industry,

which is an important economic base for Kenya. And so I think

these are some of the major reasons. But for me there is no excuse

for African leaders to sit on their hands and not act adequately

enough to intervene in this epidemic.

Mr. ROYCE. I thank you, Dr. Lamptey.

We are now going to go to our Ranking Member, Mr. Don Payne

from New Jersey.

Mr. PAYNE. Thank you very much. Thank you both, all of you,

for your testimony. As I indicated earlier, I do believe that it is

slow in coming, but I recall early discussions with President

Museveni of Uganda 7 or 8 years ago where he was at this same

stage that we find, say, President Mugabe and some of the other

presidents that had been slower in coming to realization that there

had to be education, that it is something that is here, that it is

something we have to deal with; prevention can be by distribution

of condoms, things of that nature, something that no head of state

wanted to get up and discuss, and other cabinet level people, but

26

I did see the turnaround in Uganda after several conversations, as

I indicated years ago, where there was absolutely objection to the

things that are going on now in education and prevention.

I do have a lot of hope and faith in the new president, Festus

Mogae, who has made the question of HIV/AIDS a number one

issue. One of the pharmaceutical companies is there right now with

a foundation, a Bill Gates Foundation. Bristol-Myers-Squibb is

there with this project in Botswana where the realization has been

made it is a sparsely populated country and at the rate, as you

know, the population estimates are from 68 or 9 down to 39 or 40,

is devastating and if this rate continues the country will have a

negative population growth in 8 or 9 years.

So this is a very, very serious thing but I do think that perhaps

some of the newer leadership, relatively younger leadership, like

President Mogae, can take these questions on more forthrightly to

deal with solutions to these problems.

On the educational situation, what type of educational programs,

anyone could try to answer this, have you seen initiated and what

problems do you see as relates to literacy and availability of communications techniques and materials?

Mr. LAMPTEY. Definitely lack of—— Ms. CREWE. Let me say—— Mr. LAMPTEY. Go ahead, Mary.

Ms. CREWE. Fine. After you.

Mr. LAMPTEY. Okay. Definitely lack of education. Ignorance plays

an important role in the transmission of HIV. There are several

programs that are geared toward increasing formal education of

the general population, especially for young girls and young boys.

But I believe that despite the poverty, despite the lack of formal

education, HIV-prevention programs can provide education in prevention of HIV, and the success stories that we have seen in Thailand, Uganda, and other countries have been able to do this by

simply providing relevant education to the populations that are at

highest risk.

Definitely, formal education of girls and boys would certainly

help in improving knowledge about HIV, and especially HIV-prevention, but I believe that specific prevention messages through

mass media, radio, through local theatre, community-based interventions, all of these have played a major role in reducing the

transmission of HIV.

Ms. CREWE. I would agree with that, but I would think that

there is a real difficulty, which is that if what is going on in the

society doesn’t reinforce what is happening in the schools, or in the

mass education campaigns, if the information is at this juncture

without the understanding of the general society or the willingness

of the society to accept the information, there tends to be a difficulty, and I think very often that people who have lived the reality, that overrides quite a lot of the education that they are given.

I think that we found in the school, certainly in the schools’ programs, is that we made a mistake in some ways of concentrating

the education on individual behavior where we come from a history

in our country of many generations where people are not able to

make individual choices around very crucial aspects of their lives.

They couldn’t choose where they lived. They couldn’t choose where

27

they went to school. They couldn’t choose who they would have sex

with, and people’s lives were so regimented that to now concentrate

on individual behavior, without recognizing the historical past from

which people have come and how communities operate and develop,

I think is a setback, but I do believe that education has the potential to turn the epidemic around. But my interest is that in some

ways it hasn’t yet, and I think we—it means that we have to really

assess what we are telling our people, the manner in which we are

telling them, and treating them to a whole range of other messages

that there are.

Mr. PAYNE. Thank you, Mr. Chairman.

Mr. ROYCE. Thank you. We will go to Mr. Tancredo from Colorado.

Mr. TANCREDO. Thank you, Mr. Chairman.

Mr. Lamptey, your testimony, in your testimony you specifically

cite the VCT programs, voluntary HIV counseling and testing, as

having been successful in reducing high risk sexual behavior, improving access to health care and serving as an entry point for the

prevention of MTCT. Specifically, could you tell me exactly what

aspect—why is that true? What happens in a VCT program that

you believe provides this kind of change of behavior?

Mr. LAMPTEY. I believe that the people who return to STD services are people who already have been informed of what is hazardous behavior or believe that they may possibly be infected. So

you have these people who you are attracting who believe that they

may be at risk of HIV.

Mr. TANCREDO. So you have sub-selected.

Mr. LAMPTEY. And then having been tested, if they are HIV-positive, they realize that they need to change their behavior to protect

not only their spouses and their casual partners, but also their

families in the long run, and that’s a message we give that even

though you may be infected, it is still important to prevent your

wife from getting infected and your subsequent children. For those

who are uninfected, there is obviously relief, but at the same time,

we emphasize the fact that you are lucky to have been unaffected

at this time, but you need to change your behavior to make sure

that you don’t get infected in the future.

And I think basically, going back to the other question of education, most people have adequate knowledge about how the HIV

is transmitted. I think in most countries 70 to 80 percent of the

population are aware of the causes of HIV and how it is transmitted. What they need are the skills to change behavior, the access to condoms, how to negotiate for sex, especially women, and

also all the things they need to do to empower them to be able to

make that change, the switch from high-risk behavior to low-risk

behavior. And, these are some of the things that we impart during

our voluntary counseling sessions.

Mr. TANCREDO. It is encouraging on the one hand that something

is working. It is discouraging that it is only for those people who

have already placed themselves in the position of having access, I

guess, to that kind of help, but so it begs the question of course

how do we address—what do we do about the larger population

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seling and the degree to which behaviors can be changed in any

culture.

I mean, certainly I would love to know how anyone in your situation, anyone working with this problem in Africa, addresses the behavior or addresses the situation of high risk behaviors and trying

to get people to look at abstinence, for instance, sexual abstinence,

as a positive because we could then try that in this country, but

we have many problems as a result of it, and I mentioned earlier

that there were anomalies in Africa, but that is not one. High risk

sexual activity among teenagers, and promiscuity and the kind of

problems that that brings on, we certainly have our own dilemma.

So I still wonder what can we do beyond that cohort that says,

yeah, I am ready, I want to come in and find out what is wrong?

How do we take that same lesson?

Mr. LAMPTEY. A couple of quick responses. One is that right now

STD services are very limited. They are limited to stand-alone clinics that are in urban areas. They are not available in most parts

of the country. So the first thing we need to do is to improve access.

The second, the reason why a lot of people don’t go for it is because of stigma and discrimination. That is currently in most countries, Uganda has been cited as one of the countries where this

may have diminished, but people are afraid to get tested because

of the stigma that their spouses, their family, their friends and

even workplace colleagues, the discrimination that will ensue.

And the last reason is cost. It costs anywhere from 10 to 20 dollars per person to be tested for HIV and counseled. Most countries

still can’t afford this and that is probably one of the major limitations to inadequate access to STD services.

Mr. TANCREDO. Any other comments?

Ms. CREWE. Well, we certainly agree with that. I think that the

other point is that a lot of people to be tested in absence of any

treatment means that people don’t really see that it is interesting

to know their status, if all they are going to be offered is advice

that they should use contraceptives or condoms. That is fine, but

for a lot of people they say if there is no treatment then why do

I need to know my status, why should I actually deal with this in

the absence of any support structures, any treatment, and most

people in Africa know that there are drugs available that could significantly prolong their lives and would certainly have an enormous

impact on the epidemic, and in the absence of those being available, I think there is a fair amount of cynicism of people saying

that this is a kind of fatalism. There is nothing that can be offered

to me if I’m tested, so why should I live with the anguish of knowing it.

So there’s a sense of denial, and I agree with everything that was

said before.

Mr. TANCREDO. Thank you. I think those observations are really

cogent.

Mr. ROYCE. Thank you. We will go now to Congresswoman Lee.

Ms. LEE. Let me just thank both our panelists for their very profound testimonies and also just thank you for the work that you’re

doing. I know oftentimes being on the ground, especially with Mary

and her colleague, can be, that can be overwhelming and oftentimes in the face of death and dying and pain and suffering conVerDate 11-MAY-2000 14:42 Apr 02, 2001 Jkt 069977 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 F:\WORK\AFRICA\H092700\69977 HINTREL1 PsN: HINTREL1
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stantly that you are dealing with, and also to Dr. Lamptey, I know

of your work throughout the world, and you are doing some very

creative things. And I wanted to just ask you, following up on the

previous question, could you explain the second generation surveillance and what this means and what level of resources are necessary to actually effectively implement second generation surveillance strategies?

And then let me just ask Mary, and you can think about this

while Dr. Lamptey is responding: The orphan crisis is phenomenal,

unbelievable, staggering, mind-boggling. I visited southern Africa

with Sandy Thurman and a White House delegation year before

last and I believe our findings and the report that we issued and

the public awareness that we were able to present actually was

somewhat useful in helping to begin to focus on this whole HIV– AIDS pandemic in sub-Saharan Africa, and I believe it was the orphan crisis that really initially captured the attention of many in

our country.

I was talking with a minister of health from one of the countries

in southern Africa, and she made a suggestion, and you mentioned

creative approaches to solving or beginning to solve some of the

support issues around the orphan crisis. One of those suggestions

was that children whose parents are dying of AIDS may—we may

want to look at how to help put these children in villages and begin

to develop the infrastructure of the village so that they are

transitioned into a stronger extended family unit, and the transition then would be easier and sustained once their parents passed

away and then the villages would be a stronger village because of

the economic development and the poverty reduction and issues

that had been taking place.

This was a concept that I thought may make sense. I don’t know

if we have looked at any, and I would like to just ask you if you

have seen any creative approaches in your work to the orphan crisis that really would help make—help these children live the kind

of lives they deserve to live because I know the orphanages are

under extreme duress because they don’t have the resources to take

care of 12 million children.

So first, Dr. Lamptey, let me just ask you now.

Mr. LAMPTEY. Thank you for your question. ‘‘First generation

surveillance’’ took place in the early part of the epidemic and consisted of simply doing testing of selected population groups to give

us an idea of what proportions of people were infected.

We moved beyond that to what we call the ‘‘second generation

surveillance,’’ which has a number of components. One, a systematic surveillance—serological surveillance of selected populations

all over the country, including pregnant women, some high-risk

groups like prostitutes, STD patients. That’s the first component.

The second component is also collecting behavior data that gives

a good indication of how people are behaving. The problem with serological surveillance is that it takes several years to change because of the long incubation period. However, behavior can change

very quickly, and even in the countries that have been successful,

the only way you can be truly sure that the changes in surveillance

are due to the interventions is to actually document that behaviors

have changed. Serological surveillance can change because of an inVerDate 11-MAY-2000 14:42 Apr 02, 2001 Jkt 069977 PO 00000 Frm 00033 Fmt 6633 Sfmt 6633 F:\WORK\AFRICA\H092700\69977 HINTREL1 PsN: HINTREL1
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crease in deaths. It can change for a variety of other different reasons.

The third component is to also look at AIDS cases, STD cases,

and the second generation combines all this data to be able to predict what is happening to the epidemic, the changes that are likely

to occur, and how we need to change policy and change our interventions in order to be more successful.

Ms. LEE. Thank you. Can Mary, Mr. Chairman, answer the second question with regard to the orphans, please?

Ms. CREWE. Thank you. I tend to hold somewhat unconventional

views maybe about orphans, but I think we really have to challenge the notion that the families and communities are simply

going to be able on a large scale to rear the children. I think where

they can we should encourage that, but I have a real concern,

which is that if we accept the premise that poverty in many ways

drives the epidemic, we really should not be putting policies into

place that drive poverty, and so I think to impoverish households

because we are expecting them to take in large numbers of children

is cynical and unacceptable, and it also seriously jeopardizes the

life chances of the children and those families who are not orphaned, and so we are double-jeopardizing children, I think.

The other is that I think in South Africa the whole history of the

disruption of family life, the legacy of apartheid, has meant that

lots of children are already not living with their natural parent and

they have already skipped a generation to some extent.

I think part of the problem lies in a lack of looking beyond the

status quo. We always tend to ask status quo questions and we get

status quo answers, and we have never really looked at the way

in which we integrate the department of housing, of transport, of

welfare and health and education to come together to develop one

kind of solution, and I really do think we have to look at not removing children from the community. Very often putting children

in extended families means that they move huge distances from

where they grew up. I would support the idea of some kind of very

careful community-integrated institutional care and support, however, that looks—and I don’t mean existing orphanages at all. But

I really think we have to start challenging housing departments,

architecture faculties, people to say we have to look after children

for all kinds of ethical reasons, human rights reasons, security reasons and simply to secure our future, and if putting them into villages where you have key adults in certain positions, I think we

have to experiment with that, and I am not meaning experimenting

with children’s lives at all, but failure to do that means that we

are actually simply neglecting the children, and I think, assuming

that there is an interest in southern Africa, that is actually neglecting the issue on the basis of what we believe is there.

So I am unaware of any children’s villages operating in South Africa at the response to the orphan crisis, and I think one could do

very, very fascinating work in looking at new ways of housing of

children and I think we also have to look at new families. We have

to reconceptualize how we define families and what families are.

Dr. GRIMWOOD. May I make a comment on that? The issues do

precede, though, the situation when you have an orphan problem

because children of positive families are at risk, and as their parVerDate 11-MAY-2000 14:42 Apr 02, 2001 Jkt 069977 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 F:\WORK\AFRICA\H092700\69977 HINTREL1 PsN: HINTREL1
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ents become ill, they then are not able to be fed or cared for adequately. So they are therefore at greater risk of all these problems

that have been mentioned earlier, and I think we tend to neglect

this particular group.

But then just following on to an example of dealing with this

issue, Botswana has brought a whole lot of organizations and ministries together to address their very large problem. They had

66,000 orphans, most of whom are not registered because of the

stigma attached to registering orphans. And what they have done

is present a nuclei whereby you have a house mother caring for six

or seven children, and these children are assimilated quite rapidly

into their community from whence they come once the social workers have been able to facilitate this process, and this is working

quite well, but this is an initiative which is being done in many

ministries, and I do think that there are approaches whereby we

have to address this complex problem holistically. But I would like

also to restate that we must not forget the children who are at risk

and those who belong to positive families.

Mr. ROYCE. Thank you. I want to thank all our panelists and as

we adjourn this hearing I would ask our two student interns to

stand at this time, LaTrisha Swayzer of the University of Texas at

Arlington and Alyssa Jorgenson from American University, and we

thank you again for all the time you have put in both to these

hearings and the research you have done for the Africa Subcommittee.

Thank you so much.

Mr. PAYNE. Mr. Chairman, would you yield for a minute?

Mr. ROYCE. I certainly will. Mr. Payne.

Mr. PAYNE. So that I do not hear it from my staff and the staff

on this side, let me—you have so graciously introduced your staff,

thanked them, even interns. Of course I have said nothing other

than complain about why isn’t this right here and the other. So let

me also compliment my staff and the staff of the committee and all

of the staff because they do work very closely together and they do

a good job. Thank you.

Mr. ROYCE. Thank you, Mr. Payne, and with that we are going

to adjourn this hearing. Thank you again to our panelists.

[Whereupon, at 4:25 p.m., the Subcommittee was adjourned.]

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A P P E N D I X

MATERIAL SUBMITTED FOR THE HEARING RECORD

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Ms. Crewe is the chairperson of the National Committee for School Based HIV/

AIDS Education. She has published extensively in the field. She is also the author

of the book AIDS in South Africa: The Myth and Reality.

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Æ