[House Hearing, 106 Congress]
[From the U.S. Government Printing Office]
HIV/AIDS IN AFRICA: STEPS TO PREVENTION
SUBCOMMITTEE ON AFRICA
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTH CONGRESS
SEPTEMBER 27, 2000
Serial No. 106-192
Printed for the use of the Committee on International Relations
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COMMITTEE ON INTERNATIONAL RELATIONS
BENJAMIN A. GILMAN, New York, Chairman
WILLIAM F. GOODLING, Pennsylvania SAM GEJDENSON, Connecticut
JAMES A. LEACH, Iowa TOM LANTOS, California
HENRY J. HYDE, Illinois HOWARD L. BERMAN, California
DOUG BEREUTER, Nebraska GARY L. ACKERMAN, New York
CHRISTOPHER H. SMITH, New Jersey ENI F.H. FALEOMAVAEGA, American
DAN BURTON, Indiana Samoa
ELTON GALLEGLY, California DONALD M. PAYNE, New Jersey
ILEANA ROS-LEHTINEN, Florida ROBERT MENENDEZ, New Jersey
CASS BALLENGER, North Carolina SHERROD BROWN, Ohio
DANA ROHRABACHER, California CYNTHIA A. McKINNEY, Georgia
DONALD A. MANZULLO, Illinois ALCEE L. HASTINGS, Florida
EDWARD R. ROYCE, California PAT DANNER, Missouri
PETER T. KING, New York EARL F. HILLIARD, Alabama
STEVE CHABOT, Ohio BRAD SHERMAN, California
MARSHALL ``MARK'' SANFORD, South ROBERT WEXLER, Florida
Carolina STEVEN R. ROTHMAN, New Jersey
MATT SALMON, Arizona JIM DAVIS, Florida
AMO HOUGHTON, New York EARL POMEROY, North Dakota
TOM CAMPBELL, California WILLIAM D. DELAHUNT, Massachusetts
JOHN M. McHUGH, New York GREGORY W. MEEKS, New York
KEVIN BRADY, Texas BARBARA LEE, California
RICHARD BURR, North Carolina JOSEPH CROWLEY, New York
PAUL E. GILLMOR, Ohio JOSEPH M. HOEFFEL, Pennsylvania
GEORGE P. RADANOVICH, California [VACANCY]
JOHN COOKSEY, Louisiana
THOMAS G. TANCREDO, Colorado
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 DONALD M. PAYNE, New Jersey
TOM CAMPBELL, California ALCEE L. HASTINGS, Florida
STEVE CHABOT, Ohio GREGORY W. MEEKS, New York
THOMAS G. TANCREDO, Colorado BARBARA LEE, California
GEORGE RADANOVICH, California
Tom Sheehy, Subcommittee Staff Director
Charisse Glassman, Democratic Professional Staff Member
Malik M. Chaka, Professional Staff Member
Courtney Alexander, Staff Associate
C O N T E N T S
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
Mary Crewe, Director, HIV-AIDS Unit, University of Pretoria...... 22
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
Representative Barbara Lee: Durban Report, ``Summary of Findings:
Overview of HIV/AIDS in Sub-Saharan Africa''................... 63
HIV/AIDS IN AFRICA: STEPS TO PREVENTION
WEDNESDAY, SEPTEMBER 27, 2000
House of Representatives,
Subcommittee on Africa,
Committee on International Relations,
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
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
By contrast, President Robert Mugabe of Zimbabwe has barely
uttered a word about AIDS in his 20 years in power. AIDS is
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/international__relations, 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
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
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
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.]
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 Vice-President and Director of Public Policy at the
Academy for Educational Development, a U.S.-based private
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
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 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
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 influence 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
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
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
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 community-based responses, and we are going to
work to ensure that governments protect the most vulnerable
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
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
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
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
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.
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
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 anti-AIDS 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 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
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
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
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
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 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
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
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
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
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 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
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
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
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
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 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
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
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 something that I am sure that we would be certainly
willing to discuss in conjunction with other agencies,
especially if we get a plus-up 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 anti-
retrovirals in HIV programs. To what degree can we use Brazil
as a model that we could emulate and copy on the continent of
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
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
Mr. Meeks. Thank you, Mr. Chairman.
Mr. Royce. We will go to Congressman Tom Tancredo from
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.
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
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 material that deals with HIV/AIDS
so we can begin at that level to try to stem the pandemic as
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 present and I
would like to thank you for the work that you have done on this
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
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 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
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
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 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
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 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
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
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,
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
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-to-child transmission is negligible in most of sub-
Saharan Africa. The children affected by HIV/AIDS constitute
one of the greatest tragedies of this epidemic. Over 12 million
children in sub-Saharan Africa have lost one or both parents to
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
I will briefly mention some of the steps that we have taken
for reducing the risk of sexual transmission and preventing
mother-to-child 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/
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
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. Let's work together to save the next generation of
children in sub-Saharan Africa and other countries from HIV/
Thank you for inviting me to testify today.
[The prepared statement of Dr. Lamptey appears in the
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,
STATEMENT OF MARY CREWE, DIRECTOR OF HIV/AIDS UNIT, UNIVERSITY
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
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 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
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.
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
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
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 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
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 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 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
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
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 that isn't necessarily interested in
coming in for that kind of counseling 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
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
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 constantly 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
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
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 increase 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
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
parents 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.]
A P P E N D I X
Material Submitted for the Hearing Record
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