[House Hearing, 106 Congress]
[From the U.S. Government Printing Office]




                HIV/AIDS IN AFRICA: STEPS TO PREVENTION

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON AFRICA

                                 OF THE

                              COMMITTEE ON
                        INTERNATIONAL RELATIONS
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 27, 2000

                               __________

                           Serial No. 106-192

                               __________

    Printed for the use of the Committee on International Relations


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

                                 ______

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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

                              ----------                              
                                                                   Page

                               WITNESSES

Vivian Lowery Derryck, Assistant Administrator, Bureau for 
  Africa, USAID..................................................     3
Sanford J. Ungar, Director, Voice of America.....................     6
Dr. Peter Lamptey, Senior Vice President, Family Health 
  International..................................................    20
Mary Crewe, Director, HIV-AIDS Unit, University of Pretoria......    22

                                APPENDIX

Prepared statements:

The Honorable Edward Royce, a Representative in Congress from the 
  State of California, and Chairman, Subcommittee on Africa......    33
The Honorable Don Payne, a Representative in Congress from the 
  State of New Jersey............................................    34
Vivian Lowery Derryck............................................    36
Sanford Ungar....................................................    46
Peter Lamptey....................................................    53
Mary Crewe.......................................................    60

Additional material:

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

 
                HIV/AIDS IN AFRICA: STEPS TO PREVENTION

                              ----------                              


                     WEDNESDAY, SEPTEMBER 27, 2000

                  House of Representatives,
                            Subcommittee on Africa,
                      Committee on International Relations,
                                                    Washington, DC.
    The Subcommittee met, pursuant to call, at 2:20 p.m. in 
Room 2172, Rayburn House Office Building, Hon. Ed Royce 
[Chairman of the Subcommittee] presiding.
    Mr. Royce. This hearing of the Subcommittee on Africa will 
come to order. Today, the Africa Subcommittee will look at HIV/
AIDS, the pandemic in Africa. Particularly we will look at 
steps that can be taken to prevent its spread. The HIV/AIDS 
crisis has taken a devastating toll on Africa. An estimated 16 
million Africans have died from HIV/AIDS. Two-thirds of the 
HIV-infected people worldwide, that is some 30 million people, 
are in sub-Saharan Africa. It is estimated that over the next 
20 years AIDS will claim more lives than all the lives of the 
wars in the 20th century. HIV/AIDS is damaging to Africa's 
economic development. It absorbs sparse resources. It strikes 
down people in their prime of life. It destroys social 
cohesion. The AIDS epidemic is having an alarming impact on 
children in Africa. AIDS orphans run a greater risk of being 
malnourished or of being abused and, of course, being denied 
any education, and because of women's lack of economic and 
social power, Africa is the only region in the world in which 
women are infected with HIV at a rate higher than men.
    AIDS is ripping apart African families while harming 
political stability and harming democratic development in 
Africa.
    As the Namibian Secretary of Health has written, prevention 
is the only weapon that will effectively halt the HIV/AIDS 
epidemic. There is no doubt prevention efforts must overcome 
significant cultural, educational and resource challenges, but 
the battle can be won. Progress demands a political commitment 
on the continent. President Yoweri Museveni of Uganda has 
raised the issue of AIDS in virtually every speech he has ever 
given in public since 1986. With this commitment, including 
support for anti-AIDS village education projects that I have 
witnessed, Uganda has made impressive strides in reducing its 
HIV infection rate.
    Part of Uganda's success can be attributed to the support 
of its relatively vibrant civil society backed by private 
sector entrepreneurs.
    By contrast, President Robert Mugabe of Zimbabwe has barely 
uttered a word about AIDS in his 20 years in power. AIDS is 
devastating Zimbabwe.
    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 
appendix.]
    Ms. Lee. Thank you, Mr. Chairman. I want to thank you for 
conducting this hearing and for once again focusing our 
attention with regard to the pandemic of HIV/AIDS in Africa. 
Today's hearing is another example of the attention that the 
AIDS crisis is gaining in the Congress and we are forcing the 
idea that Africa truly does matter.
    I would also like to thank all of our hearing participants 
for joining us today and for offering their testimony to help 
us focus our efforts to learn how to prevent HIV/AIDS. It is 
also extremely important to note that the global AIDS crisis 
also forces us to reevaluate our public health policy by 
including more profound steps to bring a balance between 
prevention and education and treatment and care. HIV/AIDS 
continues to wreak havoc in Africa but once again, as we have 
said so many times, Africa is unfortunately the epicenter of 
this disease.
    The World Health Organization has proclaimed that HIV/AIDS 
is the world's deadliest disease. We see now India and 
Southeast Asia and Eastern Europe and other parts of the world 
becoming victimized by this deadly disease. Yet in a Washington 
Post article it was revealed that while our intelligence 
agencies and our government knew about this as early as the 
1990's, we really didn't do much. We chose to sit on our hands. 
So now the survival of a continent is at stake. So we must 
continue to beef up our attention to put more resources into 
this pandemic.
    In July, I was privileged to have traveled to the 
International AIDS Conference in Durban, South Africa, and the 
thing at that conference was breaking the silence. For many of 
the participants at that conference it also served as a message 
of hope, breaking the despair.
    These hearings, Mr. Chairman, really do allow us to 
continue to break the silence here in Washington, DC.
    I have a report from my visit to the Durban Conference and 
it would be available for anyone who would like to look at what 
we concluded and found.
    Mr. Royce. And we will put that into the record.
    Ms. Lee. Thank you, Mr. Chairman.
    Mr. Royce. Without objection.
    [The information referred to appears in the appendix.]
    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 
voluntary organization.
    Ms. Derryck has worked in more than 25 countries, in 
Africa, Asia, South America and the Caribbean, including 4 
years teaching at the University of Liberia. She has also 
served as a Deputy Assistant Secretary of State.
    Mr. Sanford Ungar has been the Director of the Voice of 
America since June 1999, overseeing 900 hours a week of VOA 
broadcasts in English and 52 other languages which reach 91 
million people around the world.
    Prior to joining the VOA, Mr. Ungar was the Dean of the 
American University School of Communications for 13 years.
    Mr. Ungar has had a distinguished career as a print and 
broadcast journalist, including a stint as the Nairobi 
correspondent for Newsweek. He has written a number of books, 
including Africa: The People and Politics of an Emerging 
Continent. VOA and Radio Free Asia, I might add, are very 
important foreign policy tools.
    Ms. Derryck, if you would commence, and since we have your 
written testimony, we would ask you both to just summarize your 
testimonies within the scope of 5 minutes. Thank you.

      STATEMENT OF VIVIAN LOWERY DERRYCK USAID--ASSISTANT 
                  ADMINISTRATOR, AFRICA BUREAU

    Ms. Derryck. Thank you very much, Mr. Chairman, and thank 
you for holding this hearing. HIV/AIDS is one of the gravest 
threats to the global community and certainly it is the 
development challenge for Africa.
    In this oral testimony I will focus on prevention because 
my remarks have been summarized for the record, but I do want 
to make a few observations before getting to prevention. First 
of all, just to underscore the fact that HIV/AIDS is a long-
term issue, and we are going to have this problem with us for 
many, many years, as the number of those infected and the 
number of deaths indicate; and plus the fact that there is no 
vaccine in sight.
    Secondly, HIV/AIDS affects absolutely every aspect of a 
developing country from GDP to education and, therefore, for us 
at USAID it requires multisectorial responses. Thirdly, 
responses to the pandemic have to be regional because the 
disease knows no boundaries. So we cannot work in Swaziland and 
not work in Lesotho. We can't work in South Africa and not work 
in Botswana. So for us, it is important as well that we have a 
regional approach.
    Fourth, as you said, Mr. Chairman, the disease 
differentially impacts women, but for us this is a major, major 
area of concern because about 55 percent of all new infections 
in Africa occur among women, and the vulnerability of the 
disease is especially high among young girls because they have 
the lack of education, inadequate access to information and 
other generally lower economic and social status.
    Lastly, the only hope that we have at the moment to stem 
the scourge is prevention, and that is going to be the focus of 
my remarks. I, too, was in South Africa for the Durban 
Conference with Congresswoman Lee, and the bulk of my remarks 
will be based on my observations there.
    We know that we need to really focus on prevention and 
behavioral change. We know that preventing infections and 
thereby protecting the 70 to 80 percent of the population that 
is not yet infected should be our highest priority. And it is 
important to remember that, that the proportion of the 
populations that are not yet infected is very, very high. It is 
as high as 95 to 99 percent in a number of West African 
countries and our effort should be to make sure that those 
numbers remain just where they are.
    Successful prevention programs incorporate a set of 
interventions, and there are about five of them. Better 
availability of information, condoms and social marketing, 
mother to child transmission prevention, voluntary counseling 
and testing and access to support services for persons that are 
infected.
    All this means that we have to have broad multisectorial 
approaches to the epidemic.
    But prevention requires behavioral changes, and one change 
that we have advocated is increased use of condoms, and in 
Africa we see that this is really making a difference. So that 
is one prevention area.
    Our social marketing programs have been increasingly 
effective over the past years and sales have really soared. On 
the whole, more men report using condoms than women and both 
sexes are more likely to use condoms for sex with casual 
partners. But female condoms are an added measure that women 
can undertake to protect themselves. Female condoms aren't 
meant to replace male condoms but rather their availability 
increases the options available to women to protect themselves.
    I just underscored the point that I made earlier about the 
need to really think about women and ways to protect them 
because they are differentially impacted. USAID is also very 
much involved in a second preventive strategy, and this is one 
that we highlighted a lot at Durban, and that is voluntary 
counseling and testing.
    UNAIDS estimates that 90% to 95% of Africans don't know 
their HIV status. The availability of voluntary counseling and 
testing will increase access to information and services that 
will inform Africans of their status, whether they are sero-
positive or sero-negative. I talk about VCT as faster, quicker, 
cheaper. It is faster because it is just a finger prick. It is 
quicker because you find out your status in 45 minutes rather 
than having to come back in 10 or 12 days, and it is cheaper at 
$1 to $2 per kit, and with the surround of counseling the cost 
is about $12 to $24 per person and that is a dramatic decrease, 
and we think that that is really very, very promising.
    Another intervention that we are focused on is MTCT, trying 
to reduce mother to child transmissions. That is responsible 
for 10 percent of all new infections in Africa. Because 
multiple factors 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 
conference.
    Mr. Chairman, I mentioned that this is a long-term problem 
and nothing better illustrates that than the demographics on 
orphans, and that was the second major finding that occurred 
for us from Durban. This epidemic is producing orphans on a 
scale that is unrivaled in world history.
    Forty million children are estimated to become orphans by 
2010 from all causes, but new statistics indicate that that 
number might go up to 44 million children, and the overwhelming 
majority of them are going to be in Africa. And these children 
are pressed into service for their ill and dying parents. They 
have to leave school. They have to help out in the household. 
Many of these girls are pressured into sex to help pay for the 
necessities for their families, and this is a major, major 
problem.
    We visited a place, Kato Housing in Durban, and lo and 
behold, we were told that when they were doing surveys that 
they knocked on one door and they found that a 10-year-old was 
responsible, he was the adult, he was the household leader, and 
so we have seen this over and over again, and we at USAID think 
this is something that we have to work on. We call this the 
iceberg phenomenon.
    We are developing a set of community-based responses to 
support orphans, and the USAID publication, Children at the 
Brink, which is really a seminal work, identifies five basic 
strategies that we will use. I am just going to mention three 
of them. We are going to strengthen the capacity of families to 
cope with these problems of orphans. We are going to mobilize 
and strengthen community-based responses, and we are going to 
work to ensure that governments protect the most vulnerable 
children.
    We believe that the first line of defense is to enable 
children to be able to stay in school. Ultimately education is 
the key to this, so that they can acquire the skills to care 
for themselves and to be able to be effective, carriers of the 
creed that one should not engage in unprotected sex.
    So in conclusion, Mr. Chairman, we believe that we at USAID 
have led the fight in this epidemic; we know we have since 
1986. We are the largest bilateral donor for HIV/AIDS. We have 
technical expertise across the continent that is really 
unmatched.
    In the past 2 years, we have increased our investment to 
fight this problem. The Leadership and Investment in Fighting 
an Epidemic, the LIFE initiative, which has been launched by 
the Clinton administration and handsomely supported by 
Congress, is a very strong acknowledgment of the pandemic and 
last year reflected a package of interventions that have been 
shown to work.
    Since 1986, we have learned several lessons. One is the 
knowledge that you have to fight the epidemic through the 
involvement of senior leadership. Mr. Chairman, you mentioned 
President Museveni as a good example of that and hopefully we 
will see more and more African leaders coming to the fore. We 
have also learned that we can't just rely on one or two 
interventions to turn around the kind of epidemics that we see 
raging in Africa. I focused on the ones that we hope will work 
but we have got to focus on prevention, behavioral change, 
home-based care and treatment, and care for orphans and 
building infrastructure.
    We will work with other donors to increase and coordinate 
support and encourage and reinforce national attention and 
leadership such as in Uganda and Senegal, and USAID will 
address this special challenge of orphans.
    I thank you.
    [The prepared statement of Ms. Derryck appears in the 
appendix.]
    Mr. Royce. We thank you, Ms. Derryck, very much. We will go 
now to Mr. Ungar's testimony.

     STATEMENT OF SANFORD UNGAR, DIRECTOR, VOICE OF AMERICA

    Mr. Ungar. Thank you, Mr. Chairman. Thank you to your 
Subcommittee and its excellent, efficient and thoughtful staff 
for arranging this hearing today.
    I have been asked to speak about the role the media are 
playing in preventing and containing the spread of HIV/AIDS in 
Africa. We have taken a special interest in this issue at the 
Voice of America, as you know, given that an estimated 40 
percent of our listeners now live in Africa, and I might say, 
Mr. Chairman, we have been very grateful for your support and 
for your participation in programs and conferences that we have 
held recently at VOA.
    Confronted by the stark statistics and dire forecasts 
associated with most discussions of HIV/AIDS in Africa, one 
could easily be overwhelmed by the scope of this pandemic. Open 
discussion of HIV/AIDS, a frank explanation of the methods of 
prevention and treatment and the encouragement of social 
acceptance for individuals afflicted with the virus are all 
critical.
    So is the exposure of bogus explanations for the disease's 
origin and of get-rich-quick quack schemes that hold out false 
promises of a cure. The media working in Africa have a 
responsibility to convey accurate information to people who may 
be at risk of contracting the virus, but local media in Africa 
are not always operating on a level playing field, particularly 
when it comes to coverage of HIV/AIDS. They often find 
themselves subject to censorship by governments still coming to 
terms with the scope of the virus and the catastrophic 
consequences it portends for their countries.
    In the absence of unambiguous authoritative statements by 
some African leaders to break the silence and stigmatization 
associated with HIV/AIDS, popular misperceptions about 
transmission and treatment have been allowed to flourish; thus, 
making the media's role much more difficult to accomplish and 
that is why outsiders must help.
    In Africa, if I may say so, radio is king, and it is often 
the most effective means of reaching people and generating 
discussion of subjects long considered taboo. At its best, 
radio in Africa can serve as an antidote to the dearth of 
reliable medical information about how HIV/AIDS is spread and 
how it can be prevented and treated. This must be done, even at 
the risk of intruding, violating the old code of silence or 
offending sensibilities.
    I would like to describe for you a few of the ways that the 
Voice of America and some of its affiliate stations in Africa 
are working on this problem. VOA broadcasts into African homes 
in 11 languages every day. Let me repeat that. We broadcast 
into Africa in 11 languages every day. And over the past 15 
years, we have made stories about HIV/AIDS a broadcasting 
priority. Our features on the topic have tried to help some 36 
million listeners in Africa make informed choices about dealing 
with the disease.
    VOA's programs on HIV/AIDS are not limited by any means to 
shortwave radio or even to medium wave or FM. The Internet and 
television amplify the impact and the reach of these 
broadcasts. Already, VOA streams nearly 70 hours of live or on-
demand programs to Africa on the Internet each week. In urban 
areas throughout the continent, where television has begun to 
rival radio in popularity, VOA affiliate stations broadcast 
Africa Journal, a popular weekly call-in television program 
which has tackled HIV/AIDS related issues from many angles ever 
since going on the air 9 years ago. It has created the kind of 
space for open dialogue about HIV/AIDS that may be difficult 
for many African viewers to find in their own communities.
    A new VOA weekly radio-television simulcast called Straight 
Talk Africa has just been launched and will also treat HIV/AIDS 
in upcoming programs. For those programs and others, including 
this week an English language TV news-magazine shown by several 
African networks and individual stations, VOA video journalists 
with digital cameras have learned to enhance HIV/AIDS-related 
stories with powerful images.
    The effectiveness of information is often difficult to 
measure, as you know, but there are some telling signs that we 
have had an impact. Earlier this year, the director of Rwanda's 
national 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 
southern Africa.
    At the same time, VOA will create a radio documentary 
miniseries in English and Portuguese identifying certain 
communities in southern Africa and even particular individuals 
to follow over the next 2 years in order to understand better 
the impact of HIV/AIDS in the region.
    Community members themselves will give personal accounts to 
listeners across Africa of how HIV/AIDS has affected their own 
lives. Broadcasting from Washington, we recognize that our 
reach is limited and thus we rely particularly on our affiliate 
stations in Africa to carry our broadcasts on local FM 
frequencies.
    From a media perspective, they are on the frontlines in the 
battle to contain and prevent the spread of HIV/AIDS, and their 
efforts to educate their listeners truly inspire our 
admiration.
    Some might ask, what business is it of Voice of America to 
become involved in the enormous, often frustrating task, of 
fighting AIDS in Africa? My answer is that this kind of health 
reporting is in the best public service tradition of American 
journalism. Just as VOA has had an effective role to play in 
the worldwide effort to eradicate polio, working alongside 
Rotary International, the World Health Organization and the 
U.S. Agency for International Development, it is now joining 
forces with others to confront HIV/AIDS. Even if this is not 
our first line of work, it is entirely appropriate for a news 
organization like VOA to form partnerships with other 
journalists and government agencies to leverage each other's 
contributions in the fight against HIV/AIDS, especially where 
opportunities exist to reach directly the ears of statesmen and 
policymakers.
    To conclude, by now few people doubt the importance to 
international security of the effort to deal with this disease. 
As we have reported on the Voice of America, there is a 
daunting worldwide recognition of the social, economic, 
political and even strategic threat posed by HIV/AIDS, once 
viewed as a medical issue of narrow importance. But let me make 
an obvious point. No amount of international support will 
result in a reduction in the rates of HIV infection across 
Africa if there is not outspoken indigenous African leadership 
on the issue and a broader view of the problem. Local media and 
international broadcasters like VOA have the potential to 
create open spaces for a dialogue about how to prevent and 
contain HIV/AIDS, but without the bold support of respected 
national and community leaders in Africa in bringing this 
conversation closer to home, all efforts to halt the advance of 
this killer virus will be doomed to failure.
    Thank you very much.
    [The prepared statement of Mr. Ungar appears in the 
appendix.]
    Mr. Royce. I thank you, Mr. Ungar.
    Ms. Derryck, in the closing comments that Mr. Ungar was 
making, he was speaking to the fact that we need outspoken 
indigenous support from African leaders. You cited and I 
previously cited the situation in Uganda where a very 
aggressive and successful attack on AIDS through prevention 
seems to have prevailed, so much so that an AIDS rate that had 
been 30 percent, I think, in 1992 was 10 percent by 1998 in 
terms of infection rate. What are the key lessons that we can 
learn from Uganda? Is there something unique about Uganda that 
shaped their particular strategy?
    Ms. Derryck. Thank you, Mr. Chairman. I certainly do agree 
with both you and Mr. Ungar that Uganda is a good example.
    One of the keys is the leadership and the involvement not 
only of the President but of others in his Cabinet. We were 
talking the other day about infrastructures and whether the 
Ugandan infrastructure is any better than others in Africa, and 
there was a mixed opinion on that but there certainly are 
government resources that are used to maintain that 
infrastructure. So that is important. And another point would 
be that the government puts its own money into fighting the 
disease as opposed to relying simply on donors.
    I think also the emphasis on education is important. Uganda 
makes a major investment in girls' education and that, of 
course, helps to prevent further infections as well.
    And then lastly, the fact that they have been able to 
eliminate the stigma, because in so many countries when you 
declare your status then you become stigmatized and ostracized, 
and in Uganda that has not happened. In fact, there are so many 
NGOs, TASO and others, that work proactively to make sure that 
there is a caring support system available, it really does make 
a difference. So I think that all of those things help to 
contribute to their success.
    Mr. Royce. I think that in Uganda, in the health centers, 
in the schools, pamphlets are readily available in terms of the 
deep stigmatization; you have situations where young 
ambassadors who go to different schools to talk to young people 
about this problem are made up half of children that are HIV-
negative, half HIV-positive but without disclosing they share 
their stories. They do seem to do this in a way that conveys 
the information without creating in the society resistance to 
it, and it has had a remarkable effect on the decrease of the 
rate.
    One of the questions that I have is what the U.S. 
Department of Defense is doing in terms of trying to work with 
African militaries to combat AIDS because we hear that that is 
a large part of the problem with HIV infection among the armed 
services. What exactly is the DOD doing in Africa and are any 
African militaries being utilized to combat AIDS in their 
specific societies?
    Ms. Derryck. Mr. Chairman, we are very concerned about the 
role of the military because, for instance, in West Africa the 
ECOMOG (Economic Community of West African States Monitoring 
Group) troops from Nigeria and Sierra Leone and earlier in 
Liberia really are vulnerable to the disease and militaries are 
a vector of the disease.
    We have special waivers now within USAID that will allow us 
to work with African militaries, and we have one program that 
is beginning in Nigeria. We have talked about the fact that 
testing would be a very good first step, and with the new 
cheaper VCT that I talked about, then that is one possibility, 
but AID will plan to work closely with DOD because it is a 
natural collaboration for a problem that really does span the 
entire continent.
    Mr. Royce. Thank you. I wanted to ask Mr. Ungar a question, 
too, about which African governments are the greatest offenders 
in terms of censoring independent broadcasting. What I wanted 
to know was, are HIV and AIDS prevention messages ever blocked 
by governments or do they take a laissez-faire attitude and 
allow the broadcasts?
    Mr. Ungar. Well, Mr. Chairman, of course, we attempt not to 
be censored by any governments in Africa or anyplace else in 
the world, and the programs that we send in to Africa are going 
by shortwave, by medium wave, by FM through affiliates and now 
increasingly by television and the Internet as well.
    I would say that there are some countries that are known to 
have suppressed local media coverage of HIV/AIDS. Zimbabwe 
would be one that I am sure you are familiar with. This has 
been rather taboo to be spoken of in Zimbabwe over recent 
periods. There is a remarkable parallel between the countries 
who have made progress and those in which there has been open 
discussion in the media.
    For example, in Uganda, the discussion has been more open 
in the local media. In Senegal, that is certainly the case as 
well. Senegal has been a leader in West Africa. I think 
increasingly in Nigeria these issues are openly being 
discussed. The media have become freer with the return of 
civilian rule, as you know. We are particularly concerned that 
the VOA programs, the countries that would have the greatest 
impact in Africa, that these issues be treated. I would say 
that we have made a particular effort in all of our 11 
languages that are going to Africa, but especially Hausa in 
Nigeria, Hausa and English in Nigeria, and then, of course, our 
Horn of Africa service, including our inherent broadcasts where 
our largest listenerships in Africa are in Nigeria and 
Ethiopia, and we have been treating these issues with 
particular care there.
    Mr. Royce. I thank you very much. I want to go to my 
colleague, Barbara Lee of California, for her questions at this 
time. Let me say she has been a leader on this issue in the 
House of Representatives. Barbara.
    Ms. Lee. Thank you, Mr. Chairman.
    Let me thank you both for your presentations today. I want 
to, Ms. Derryck, state to you that I think given the minimal 
resources that you have that you are doing a fantastic job, at 
least in helping to begin to respond to this pandemic, and we 
are going to have to figure out how to make sure that 
additional funding is available for the work that you do.
    I was in Nigeria last year, it was actually on World AIDS 
Day, with Mr. Gejdenson and also very recently with President 
Clinton on his visit to Nigeria and to Tanzania. One of the 
issues that came up and that I read about and had discussions 
about had to do with the issue of blood transfusions and 
infections, the high rate of infections as a result of blood 
transfusions. I have talked to several officials over at USAID. 
I think I have talked briefly with yourself, Ms. Derryck, and I 
want to follow up and just find out if, in fact, we have the 
statistics with regard to the most infected countries, but 
especially with Nigeria. We heard maybe 10 percent of the 5 
percent of the infections were as a result of blood 
transfusions. But even if it is 2 percent in a country such as 
Nigeria, that is an enormous amount of pain and suffering that 
doesn't have to exist, because we know how to deal with blood 
banks and blood transfusions.
    So can you give us some feedback on that, what we know 
about that and what we are doing, if anything, to help African 
countries deal with that, deal with blood transfusion issues?
    Ms. Derryck. Thank you, Congresswoman.
    The whole issue of blood transfusions does come up 
frequently. I do not know an awful lot about the issue because 
I think it is something that we work with CDC on, and I will 
have to get back to you on the specifics of this. But let me 
just say a word about infrastructure, because we think about 
that a lot in terms of dealing with the pandemic. And the whole 
issue of blood transfusions and maintaining the purity of those 
transfusions I think really is compromised by imperfect 
infrastructures that we see all over the continent. It goes 
from the potable water to the lack of trained technicians, to 
the inability to carefully and systematically monitor blood 
transfusions. We see it basically throughout health care 
systems and other infrastructure, but certainly for health care 
systems in terms of HIV/AIDS.
    But on the specifics, we will have to get back to you.
    Ms. Lee. Thank you very much. Let me also just ask with 
regard to the programs in Uganda and Senegal, which I believe 
are the models, the examples for effective prevention and 
treatment, have they had the issue of blood transfusions to 
deal with? And then secondly, what is it about their approach 
and their strategies that have allowed them to be the model 
countries that have been able to get this under control?
    Ms. Derryck. Let me just ask my colleague about Uganda and 
the blood transfusions.
    My colleague says that the European Union has been involved 
over the long-term, and early on we were supporting some blood 
transfusions as well.
    Ms. Lee. And what are the elements of both countries' 
strategies that could be adaptable in other countries that they 
really need to know that we maybe could support?
    Ms. Derryck. First of all, it is that whole question of 
leadership and it is not only President Museveni but it is Mrs. 
Museveni as well, and when we start talking about stigma and 
women, that becomes an important component of what has happened 
in Uganda.
    It is also the question of their investing their own 
resources in the fight of this. They have enlisted even leading 
entertainers in songs who have performed on this. They also 
have made a serious investment in nongovernmental 
organizations, and those NGOs spread the word and make sure 
that they have a very strong network that is supportive of 
people in the country.
    Uganda has been fighting this for so long, but we have had 
more than a decade of experience with this. So, therefore, 
there is a culture now of accepting the disease and culture of 
confronting the issue, and so that helps as well.
    Senegal has been very successful in maintaining a low 
prevalence because they too have had a major investment in 
research. Senegal has also worked very successfully with 
prostitutes and prostitutes who follow the military, and so 
they have been able to again publicize the fact of prevention 
and of safe sex. So that has been a major element of their 
success. But in both countries it is the investment of their 
own resources and in senior leadership and it is, as you said, 
breaking the silence, breaking the stigma of the disease.
    Ms. Lee. In a perfect world, what dollar amount of money 
should we be looking at as a U.S. contribution?
    Ms. Derryck. Oh, I am so glad that you asked me that. Thank 
you.
    To halt the epidemic, we think that we need $1.2 billion to 
$2 billion. That is just for prevention per year in Africa. We 
need $3 to $4.9 billion for prevention and care. But those 
amounts exclude the infrastructure improvements that are 
necessary long-term.
    Ms. Lee. What is our budget now?
    Ms. Derryck. For Africa, it is $114 million for 2000 and 
the request is $139 million for 2001. So that is clearly not a 
very significant amount to begin to deal with this.
    Ms. Lee. Why didn't you request $1.3 billion?
    Ms. Derryck. I would have to defer to the Administrator and 
to our own colleagues on that one.
    Ms. Lee. Thank you.
    Mr. Royce. Thank you, Congresswoman. We will now go to 
Congressman Greg Meeks of New York.
    Mr. Meeks. Thank you, Mr. Chairman. Let me just ask, just 
picking up right where my colleague Barbara Lee left off, 
some--you know, you talk about infrastructure. Some have argued 
that the underlying problem with HIV is the poverty that is in 
various countries or on the continent. To what degree is that 
true and do you think that we have to wipe out the poverty that 
is going on on the continent before we can really get to the 
HIV/AIDS problem?
    Ms. Derryck. Thank you, Congressman, because this really is 
an issue for all of us who work in development. In the Africa 
Bureau, we say that our major goal, our major priority for all 
of our activities, is poverty alleviation. To get at poverty 
alleviation, you have to deal with education and you have to 
deal with increasing incomes; you have to deal with issues of 
nutrition, family planning and health.
    There in that nexus of problems we see certainly an 
inability to respond to HIV/AIDS. When we begin to talk about 
anti-retroviral drugs in Africa, I am reminded of the very 
graphic demonstration that my colleague gave. People said that 
we just want to see what these anti-retrovirals look like. So 
he went and got them out of a refrigerator, which most people 
do not have. He noted that you have to take them at a certain 
time, but people did not have clocks or watches, or a constant 
electricity even if they had the clock, and you need to have 
potable water. So just those three things demonstrated that 
maybe this is not the best solution to the problem, but it gets 
back to poverty and to the lack of infrastructure and sometimes 
back to just the basic adequate nutrition and diet. So they are 
all really interrelated, but I don't think that we can wait to 
solve the poverty problem, which is really long-term, before we 
have a massive attack on HIV/AIDS.
    Mr. Meeks. Well, given that, we know that some major 
manufacturers, major pharmaceutical manufacturers, have 
indicated they are going to reduce the costs or the charge for 
the retroviral drugs. Do you see any of the African nations 
being able to take advantage of that? Have they been taking 
advantage of it, and is that going to help, given still, even 
with the structural problems of not having refrigeration, 
electricity, et cetera?
    Ms. Derryck. We welcome that kind of a contribution and we 
plan to--I guess all U.S. Government agencies plan to work as 
closely as we can with them. I am pretty sure that we will 
probably have to begin small and look at some possible 
demonstration programs, but they have to be in places where 
there is at least the potable water and the basic 
infrastructure that can accommodate those kinds of 
interventions.
    We also have to make sure that the anti-retrovirals will be 
available long-term because the epidemic is long-term and so we 
are going to need the resources and the material over at least 
the next decade.
    Mr. Meeks. Well, I was recently in Ghana and they were 
talking about there, even with the reduced charges which, you 
know, they admit it was substantially cut but even with the 
smaller costs they could not afford it on a large-scale basis. 
Has there been anything that we have done or looked at with 
reference to maybe generic drugs and the distribution of the 
generic drugs that could further reduce the costs on the 
continent, the manufacturing of the drug somewhere on the 
continent?
    Ms. Derryck. Again, I am not really aware of those kinds of 
efforts, and I would have to check with my colleagues and get 
back to you on that. I can tell you a little bit about it, that 
Nevirapine and the fact that it now is a very cheap drug that 
can be used for MTCT, and that it is certainly being used in 
Uganda and in some other countries.
    Mr. Meeks. I know we talked about the dollar amount. I 
don't know whether your agency or others--I mean, I happen to 
have seen when we were in Ghana on the ground there a company 
that was manufacturing and producing a generic brand of drug 
there, and I was wondering whether or not that is something 
that you or USAID have invested in or something that you would 
be interested in looking at?
    Ms. Derryck. As far as I know--again, I will have to check 
this. As far as I know, we have not invested in this and it 
would be 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 
Africa?
    Ms. Derryck. The Brazil program seems to have had some 
considerable success in prolonging lives, but I think we have 
to look at the prevalence rate there. Brazil has a health care 
system that is much more advanced than those that we see in 
African countries. Brazil has the eighth largest economy in the 
world, and while it has these real pockets of poverty it is, as 
you know, far more able in terms of infrastructure to support 
this kind of long-term investment. They also are a richer 
country than almost any of the African countries that we are 
talking about.
    But I don't know. For Africa, because the prevalence rate 
is high and because the resources are so limited, we think that 
we really do need to focus on prevention and to put the 
resources that we have in a major way toward prevention as 
opposed to providing the anti-retrovirals as they have in 
Brazil.
    Mr. Meeks. Thank you, Mr. Chairman.
    Mr. Royce. We will go to Congressman Tom Tancredo from 
Colorado.
    Mr. Tancredo. Thank you, Mr. Chairman. I have a couple of 
questions for actually both of you, I think, starting with Ms. 
Derryck. There are certain anomalies that present themselves 
when you look at the development of AIDS on the continent of 
Africa, one being the fact that although research has shown 
that better educated people are more likely to use condoms, but 
that especially in southern Africa the teaching and the nursing 
professions have been especially hard hit, essentially 
decimated. For either one of you, really, how would you explain 
this phenomenon or what I would call an anomaly?
    Ms. Derryck. It is one of these really sad phenomena. I was 
talking to Sandy Thurman about this the other day, not about 
this but about the importance of education.
    Mr. Tancredo. I know you mentioned it in your testimony.
    Ms. Derryck. It is that people should be more likely to 
change their behaviors in ways that would help them to avoid 
the disease. I was talking about in the case of Thailand, that 
that wasn't necessarily true in the general educated 
populations. We see teachers in southern Africa who are 
infected because--well, first of all because the infection rate 
is so much higher there. Second, that they are desirable, 
socially desirable, partners and, therefore, they may have more 
opportunities and they have unsafe sex. So that is one reason, 
and because the infection rates in the region are so high that 
makes it difficult, too.
    We are losing teachers now at a rate faster than they can 
be replaced. This has, of course, devastating consequences for 
schools and for the ability to continue to even operate 
classrooms in some places.
    There was an interesting piece in the New York Times about 
a month ago that talked about the experience of teachers in 
rural Cote d'Ivoire, the other side of the continent, but the 
fact that they are out there, they do not have access to 
condoms; they are desirable partners and there are more young 
women there, and that that is the nature of human beings and 
that is the consequence. So it is the lack of attention. It is 
the lack of access to condoms. It is the lack of attention to 
the messages, if they get out there, and it is basic ignorance.
    We also know that 15- to 19-year-old girls in Kenya, 80 
percent of them have no knowledge of ways to protect themselves 
from HIV/AIDS. So when you have students like that and teachers 
who should be more knowledgeable, then you can see that you are 
going to have a recipe for a very high prevalence rate.
    Mr. Tancredo. Well, exactly. It is such a challenging 
aspect of this because, of course, we want to rely upon 
education as the solution to not just this problem but so many, 
and yet it just doesn't seem to work. It doesn't seem to be the 
place in which--or the sort of cultural activity, societal 
activity, that we can rely upon in this particular area in 
order to accomplish the goal. It is a very disconcerting aspect 
of this, I might say.
    I don't know, Mr. Ungar, do you have an observation that 
you would like to share?
    Mr. Ungar. Just briefly, Congressman, more so from my prior 
work at Africa than my duties now at Voice of America. I would 
only add two things to what Ms. Derryck said. One is that many 
teachers in Africa work away from their homes at schools, and 
do not have their families near them and therefore may have 
multiple partners. The other thing is that very often teachers 
are so poorly paid and may become involved in other things for 
the sake of earning more money.
    I would just note that in the programs that we are about to 
do, and I can't remember if this was before or after you came 
in, but I was talking about this initiative we are making in 
southern Africa in English and Portuguese, and in the Cape Town 
area working with our affiliate Bush Radio. In Cape Town we are 
going to be having teen town meetings. We are going into the 
schools and that is part of the innovative aspect of this, is 
not just to be sort of broadcasting out there but to draw the 
schools in from the outset in these particular programs, and we 
are hoping that that will reach a greater number of teachers as 
well as students than our ordinary programs might have.
    Mr. Tancredo. Along the lines then of some of the issues 
with which we may be uniquely dealing, I should say, in Africa, 
although not entirely, but the practice of female circumcision, 
does it have an effect, do you think, on the spread of AIDS and 
ritual scarification? What about either or both of those two 
practices?
    Ms. Derryck. Yes, but before I go to that I just want to 
say one more thing about education. Realizing that education is 
so central to dealing with this pandemic, we are having 
advisors work with ministries of education, again this is a 
multisectorial approach, but to make sure that ministries are 
aware of this problem certainly of teachers, but also of making 
sure that there is curricular material that deals with HIV/AIDS 
so we can begin at that level to try to stem the pandemic as 
well.
    So education is central. The teachers are one aspect of it, 
but the curricular response is another one.
    In terms of female circumcision, there has been some work 
done on this and obviously if the knife or the implement that 
is used is not clean and disinfected then one runs the risk of 
becoming infected. But there has also been some interesting 
work, and it is not proved yet, that one of the reasons that 
there might be a lower infection rate in West Africa is because 
more young men, babies, are circumcised. So it is an 
interesting little twist there, but again as I said that has 
not been proved. But certainly female circumcision is an area 
that can increase the spread as opposed to in any way prevent 
or eliminate it.
    Mr. Tancredo. And ritual scarification?
    Ms. Derryck. I don't know of any evidence on that. Again, I 
will have to check with my colleagues and get back on that.
    Mr. Tancredo. Thank you very much. Thank you, Mr. Chairman.
    Mr. Royce. Thank you, Mr. Tancredo.
    Before I go to Don Payne, let me say that this will 
probably be the last hearing of the Africa Subcommittee for 
this Congress and I want to express all of my appreciation to 
all of my colleagues, especially to the Ranking Member of this 
Subcommittee, Congressman Don Payne. I just want to say, Don, 
that I have very much enjoyed working with you over the last 2 
years. I look forward to continuing efforts to see that America 
is as committed to Africa as it needs to be.
    I also, Don, wanted to thank the staff here of the 
committee for their important work. Don, if you would like to 
question our witnesses now. Thank you.
    Mr. Payne. Thank you very much, Mr. Chairman. First of all, 
I would ask unanimous consent to have my opening statement 
entered into the record.
    Mr. Royce. Without objection.
    Mr. Payne. Thank you. Secondly, along the same line, I 
certainly would like to, as I have done in the past and this is 
really not the mutual admiration society, he said it and I will 
say it now but I have done this before so it is not new, but I 
would certainly like to commend the gentleman from California, 
Mr. Royce, our Chairman, for the interest and dedication that 
he has taken on this responsibility.
    I have been a Member of this Subcommittee now for 12 years 
and I have served with democratic chairpersons and republican 
chairpersons, and one thing that I must say is that out of all 
the committees I have served on this has been about the least 
partisan, but I also have to say that Mr. Royce has taken the 
seriousness of his responsibilities and he was at a 
disadvantage coming in because he did not know as much about 
Africa as he did about other parts of the world but I must say 
that I don't know of anyone who has learned more, has become 
more expert and has focused on the main problems of the 
continent of Africa. And I have said that when he has been 
present and I have said it when he hasn't been present and I 
would like to thank you for the work that you have done on this 
committee.
    Mr. Royce. Thank you. I appreciate it.
    Mr. Payne. Let me ask a question or two in regard to, first 
of all, I think that the fact that we are discussing HIV/AIDS 
in Africa as relates to the continent is really a quantum leap 
forward because, you know, 4 years ago, 8 years ago, 6 years 
ago, 3 years ago we could not have the level of discussion that 
is necessary. As we know when things are kept in the closet, 
back in the change of the century mental health was something 
that was kept away from public discussion, it was something to 
be ashamed of, something people didn't want folks to know there 
was someone who may have a mental problem in their families, 
and until we started bringing mental health out into the open, 
discussing it here in the United States, did we finally start 
to come up with some kind of ways to remedy the situation. It 
is the same thing with HIV/AIDS in the United States. There was 
a lack of discussion for it and, of course, in particular in 
Africa there was even less. So I believe that one of the first 
steps is recognizing that there is a problem. Up until the 
present, there has been the denial that there is a problem, and 
so that is a victory, a very big victory, in my opinion.
    So at least now in many areas we do know that there is a 
recognition of a problem and at different degrees though and 
levels we will see an attack on the situation.
    Just 2 or 3 weeks ago I attended the Millennium Celebration 
in New York and at a luncheon that was sponsored by the 
Corporate Council on Africa, about 5 or 6 or 7 heads of state 
were present, and some prime ministers were present, Mr. 
Mugabe, President Festus from Botswana, Mozambique's president 
and on and on, and the whole theme of that luncheon was HIV/
AIDS and they each took the mike and each talked about the 
problem in their country and each talked about what they were 
attempting to do. They varied from country to country, but as I 
indicated, 2 or 3 years ago you could not get that kind of 
discussion out in public, in the open, with heads of state 
saying we have a problem, we need help, this is what we are 
doing, it is not enough.
    So for that reason, I do believe that with education, with 
awareness, we could at least have this situation really known 
and therefore start to deal with it. We know that there are a 
lot of obstacles to overcome.
    Let me ask in relation to the legislation and let me, as I 
ask this question, commend Ms. Lee and Mr. Leach for the Global 
AIDS and Tuberculosis Relief Act but, Ms. Derryck, could you 
tell me how the act is coming along? What steps have been taken 
by the administration, unless you have already answered it, and 
the World Bank to set up the AIDS trust fund foreseen in H.R. 
3519? And secondly, have donors come in? Have we donated? Have 
others donated? Has there been participation? And when do you 
expect the fund, if it hasn't started operating, to begin 
operating?
    Ms. Derryck. Thank you, Congressman Payne. Before I begin, 
may I just join in your mutual admiration society because it 
has really been a pleasure. You know, we are energized by the 
concern that the both of you have shared and by your dedication 
and your knowledge of the continent. So I think that it is a 
synergy that helps us all and we are grateful to you.
    I would also like to underscore the fact that there really 
has been a sea change in attention among African leaders to 
this problem.
    Last year at this time, at the ICASA (International 
Conference on AIDS and STDs in Africa) meeting in Lusaka, the 
prime minister of Mozambique stood and talked about the need 
for males and male leaders to change their minds, and that was 
revolutionary. We have seen within a year's period of time a 
total sea change among African leadership. So you are right.
    In terms of the trust fund, we are very supportive of it, 
and we hope that there is going to be very good coordination 
because we see it within USAID as a real opportunity for 
synergy.
    Our concern is that we don't want to see it come at the 
expense of our ongoing programs. I know I am like a broken 
record and say that all the time, but the pandemic is so huge 
that additive resources are welcome. It is going to take some 
time, I think, for the Bank and Treasury and us to get together 
for the financing. So we anticipate that it is likely to become 
operational over the course of the next 6 or 8 months.
    I am not aware yet of other countries contributing to it, 
and I can just ask my colleagues if they are.
    No, we do not know of any others, but I am sure that it is 
something that will be discussed in upcoming meetings when 
donors have a chance to get together.
    Mr. Payne. Thank you. I would hope that the administration 
would push that in the future when those meetings come up.
    Let me just conclude with this question. We have heard that 
the fact that poverty now is certainly put in almost as the 
number one problem and we have heard especially President Mbeki 
question whether HIV/AIDS is in itself what it is, but that 
tuberculosis and malaria and poverty in general are perhaps 
more of a problem than HIV/AIDS. It does make a lot of sense 
that poverty--indeed, when you have poverty and a lack of what 
you need, things are certainly going to be worse, but the fact 
that in spite of poverty--poverty was worse or as bad in Africa 
20 years ago, 10 years ago, 5 years ago, as it is today, but 
over the past 20 or 25 years we have seen the life expectancy, 
in spite of this poverty, it has been there, it has been 
horrible, we have seen the life expectancy, in spite of this, 
tuberculosis was always there, malaria was always there, 
cholera always got into the water, et cetera, but we have seen 
the average age, life expectancy increase, actually even 
Botswana getting up to the high sixties and many countries in 
Africa gradually increasing each year. With the question of the 
HIV virus, is it everyone's opinion that this is just one of 
these seven or eight medical problems that we have in Africa or 
this HIV virus, which causes AIDS, is it a new serious kind of 
situation that really breaks down all of the previous gains 
that were made in spite of the poverty and these diseases that 
have always been around?
    Ms. Derryck. I thank you, Congressman.
    When we look back over time, you are absolutely right, that 
the gains in lower mortality and morbidity have been really 
very, very positive until now. When you look at the new charts 
that the U.S. Bureau of the Census has done and you see what is 
happening, the inverted pyramid and these spikes in mortality 
in AIDS-affected countries, you do see that this is something 
that is new and unprecedented.
    I just want to go back to what you said about tuberculosis 
and malaria because there is always this contention that 
malaria kills more people than HIV/AIDS. We know now that that 
is not so; that AIDS killed more people in 1999 and 2000 than 
malaria. So this is something that is new. In the United 
States, we have been able to deal with this because we have the 
infrastructure and we have the resources, and we put a lot of 
money into dealing with this, and we also have the media and 
other venues by which we can get people to change behaviors.
    We don't see that in Africa. So as far as any of us know, 
it is something that is new. There is no cure. There is no 
vaccine. This is a different kettle of fish than we have seen 
previously, and it really does threaten to wipe out the 
development gains of the past 40 years.
    Mr. Payne. Thank you very much.
    Mr. Chairman, let me just also, as I complimented you, also 
thank you very much, Ms. Derryck, for that answer, thank 
colleagues on the other side of the aisle. As you know, Mr. 
Campbell will be leaving the House, he may be in the Senate, he 
may not be. That remains--none of us know where any of us are 
going to be on November 7, so we will leave that up to whatever 
happens, but I would certainly like to thank Mr. Campbell for 
the initiatives that he took and our many travels together, and 
also Mr. Amo Houghton, who has been a long-time Africa hand and 
was such an addition to the committee, and also on the other 
side, Mr. Tancredo, who took his first CODEL to southern Sudan. 
I told him that the only way you can take a CODEL is you have 
got to go to southern Sudan first and then you can go on the 
other ones.
    Mr. Tancredo. And I believed him.
    Mr. Payne. He believed me. I don't know if there is a 
bigger odd couple on every other issue in the world, but 
sitting around the campfire going to our hut for the night, I 
don't think there is anyone that I could be on the same page 
with in the middle of Sudan than Tom Tancredo. So I would like 
to thank you again for traveling there with me. Thank you.
    Mr. Royce. Thank you. I would also just like to thank Tom 
Sheehy, the staff director and Malik Chaka and the other 
members of the staff, including our interns that assist us here 
and do such a fine job. So we thank you all.
    We want to thank our witnesses, our first panel, for making 
the trip down here today. We thank you so much.
    We are now going to conclude our first panel and go to the 
second panel, so we will do that at this time.
    Dr. Peter Lamptey is the Director of the Arlington, 
Virginia based Implementing AIDS Prevention and Care Project, 
or IMPACT project as it is known. He is also the Senior Vice-
President of HIV/AIDS Programs with Family Health 
International, which is an NGO with more than 12 years of 
experience in HIV/AIDS programming in more than 50 countries, 
and prior to directing IMPACT Dr. Lamptey directed the AIDS 
Control and Prevention Project from 1991 to 1997, and the AIDS 
Technical Support Project from 1987 to 1992. He was born in 
Ghana. Dr. Lamptey received his medical degree from the 
University of Ghana. He earned a Master's Degree in public 
health from UCLA and a doctorate in the same field from Harvard 
University.
    Ms. Mary Crewe, with us through videoconferencing from 
South Africa, is the Director of the HIV Unit at the University 
of Pretoria. She has been involved with HIV/AIDS work for more 
than a decade. She helped to develop and manage the 
Johannesburg AIDS Center, which was the largest program in the 
region.
    Ms. Crewe is the chairperson of the National Committee for 
School Based HIV/AIDS Education. She has published extensively 
in the field. She is also the author of the book AIDS in South 
Africa: The Myth and Reality. It is good to have you with us, 
Mary.
    Also with us is Dr. Ashraf Grimwood, Director of the 
National Aids Convention of South Africa (NACOSA), with our 
U.S. AIDS Mission in South Africa. It is good to have you with 
us as well.
    Mr. Royce. With that said, let's let Dr. Peter Lamptey open 
for 5 minutes. Again, Peter, if you could keep it brief and 
just a summation because we have your testimony here for the 
record, and then we will go to Mary Crewe's testimony.

   STATEMENT OF PETER LAMPTEY, SENIOR VICE PRESIDENT, FAMILY 
                      HEALTH INTERNATIONAL

    Mr. Lamptey. Thank you, Mr. Chairman. I would like to 
especially thank you and this Subcommittee and all the Members 
of Congress, especially Congresswoman Barbara Lee, who have all 
been very supportive of the fight against the HIV/AIDS epidemic 
in developing countries.
    As this Subcommittee requested, my testimony today will 
focus on the status of HIV/AIDS in Africa and the effective 
strategies for prevention and care.
    During the last 14 years, Family Health International, with 
support from USAID, has been involved in HIV/AIDS programs in 
more than 60 developing countries. We have partnered with more 
than 800 nongovernmental organizations and community-based 
organizations of all types. Humbly, I would suggest to you that 
as a result of our experiences around the world with these NGO 
partners, we have an extremely broad, deep and unique 
perspective on the HIV/AIDS epidemic.
    African countries south of the Sahara have the worst HIV 
epidemics in the world, as has been said by previous speakers. 
Adults and children are becoming infected with HIV at a higher 
rate than ever before. In sub-Saharan Africa with nearly 25 
million people living with HIV and 4 million new infections 
every year, most of the progress achieved in the health and 
overall development is being reversed by this epidemic. In 
countries with high adult HIV prevalence, the chances of a 
young, uninfected adult encountering an infected sexual partner 
can be as high as 40 percent.
    About 50 percent of HIV infections in Africa are in women, 
which also result in higher mother-to-child transmission, as 
has been described earlier.
    Access to anti-retroviral therapy for the prevention of 
mother-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 
AIDS.
    In our HIV prevention and care programs, we have been 
guided by some key principles. These include the need to 
improve the capacity of implementing agencies in developing 
countries to implement successful HIV/AIDS programs. The second 
principle is to work closely with community-based 
organizations. This is extremely important. Indeed, a full 90 
percent of the USAID-funded IMPACT activities are implemented 
by NGOs and CBOs. The third principle is involvement of the 
community, especially people with HIV and those affected by 
AIDS.
    I will briefly mention some of the steps that we have taken 
for reducing the risk of sexual transmission and preventing 
mother-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/
AIDS.
    In conclusion, the HIV/AIDS epidemic continues its 
relentless spread, and the response is still woefully 
inadequate in most countries. More than 5 million people become 
infected every year; yet denial and discrimination still 
prevail.
    However, our experiences overwhelmingly tell us that 
success in HIV prevention is achievable. We need to apply the 
lessons learned from successful prevention programs to other 
settings and expand the coverage of these programs.
    We need to double our research and be forced to find a 
cure, or at least more effective and affordable therapies and a 
vaccine. We know what we need to do. We know that HIV 
prevention can work and care is urgently needed for those 
currently living with HIV/AIDS.
    Mr. Chairman, I think you will agree that there is nothing 
worse than watching an innocent child or mother die a horrible 
death. Let's work together to save the next generation of 
children in sub-Saharan Africa and other countries from HIV/
AIDS.
    Thank you for inviting me to testify today.
    [The prepared statement of Dr. Lamptey appears in the 
appendix.]
    Mr. Royce. Thank you, Dr. Lamptey, for your testimony 
before us today. We turn now to Pretoria and to Ms. Mary Crewe.
    If you would give us a summation of your testimony, Mary, 
thank you.

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

    Ms. Crewe. Thank you very much. Thank you for the 
invitation to be with you. I very much appreciate the 
opportunity to participate fully in your debate.
    The crucial issues have been touched on in terms of AIDS in 
Africa, and that information has been transmitted to me. I have 
been looking more specifically at AIDS in South Africa. As you 
know, we have the fastest growing epidemic in the world. 
Approximately 22.4 percent of pregnant women are positive in 
South Africa. We know that we have up to 1,700 new infections a 
day, and I think we are at a crisis of unprecedented experience 
and magnitude.
    I think there is a problem with the mike. Can you hear me?
    Mr. Royce. No, you are fine, Mary Crewe. We can hear you 
without a problem.
    Ms. Crewe. All right. What has happened in South Africa is 
that there has been a strong commitment to HIV/AIDS since 1994 
and to some extent before that. We have had a general fiscal 
allocation for AIDS. We have had many instances to deal with 
the epidemic but there is a lack of a number of trained health 
care workers. We have various ranging programs. We have a 
number of strategic plans, and I think it is fair to say that 
in South Africa we have a very big HIV/AIDS population, but the 
paradox of this is that it has not translated into real 
behavior change. It has not translated into ending this 
incredible stigma and prejudice that was related to earlier, 
and simply it hasn't translated into mass community 
mobilization to get involved through an AIDS-free country.
    As has been alluded to also, I think the role of the 
government recently has been somewhat controversial and the 
debates that have been conducted between the government, the 
media and various community groups have, I think, done two 
things. One thing is that they have set back the campaign 
around HIV/AIDS to some extent, but I think more interestingly 
they have raised the profile of HIV/AIDS to the level of 
emotional debate in a country which perhaps hasn't happened 
before, and there has been some awareness about the impact of 
AIDS on the country. I think it is crucial that, as our 
president has suggested, that we do deal with the issues around 
poverty but we have to look at poverty and unemployment.
    South Africa still has what is classified as the fastest 
growing HIV/AIDS epidemic in the world. It is estimated that 
22.4 percent of pregnant women are currently infected, with 
close to 1700 new infections per day. There have been many 
attempts to deal with the epidemic ranging from the life skills 
program in schools, to training of health care workers and 
general AIDS-awareness campaigns.
    This has created something of a paradox in that South 
Africa has a very HIV/AIDS-aware population but one in which 
very high levels of stigma, prejudice and denial exist and the 
awareness has not been translated into behavior change nor into 
great community mobilization to get involved and campaign for 
an AIDS-free country.
    The role of the government has of late been controversial. 
The debates that have been conducted between the government, 
media and various community groups have done two things. They 
have raised the profile of HIV/AIDS in the public consciousness 
and have created some debate about the impact of HIV on South 
African development. However, the linking of AIDS to poverty as 
the causal agent has caused some confusion and a reluctance to 
admit that behavior change is crucial. As with previous 
campaigns that have been controversial, this has served in some 
ways to deflect the urgency, but for most people working in HIV 
and AIDS service organizations, research centers and hospitals 
and clinics, the belief is that it is business as usual and 
that the campaigns for prevention and care should not be 
affected and that the debates can give extra impetus to their 
work.
    AIDS workers have always had to deal with high levels of 
doubt and denial, and this has allowed for a new take on how 
best AIDS education should be given.
    These are areas of great concern. One is the inability of 
communities to cope with the demands of care and support. There 
are few policies which offer guidelines on crucial aspects of 
the transmission of HIV. We await decisions on the use of drugs 
in MTCT, as well as on the controlled use of anti-retrovirals. 
There also needs to be a careful decision on the provision of 
drugs in the absence of a real support infrastructure. Access 
to drugs is a highly charged issue, as is the question of 
compulsory licensing and parallel imports.
    There is no formal policy on breastfeeding or on voluntary 
counseling and testing. There is no policy on the care for 
families and particularly orphans where it is quite clear that 
the so-called extended families will not be able to cope with 
the levels of care and support required. There is no policy on 
support for care givers and no real understanding what the 
impact of home based care will be. There seems to be even at a 
policy level an indecision and a lack of political will.
    But there is much that is happening in communities through 
NGOs and CBOs. There are home based care programs, and there is 
the exciting potential of the development of a home based care 
kit that is likely to transform care in most communities. There 
are support services, food aid as well as community education 
and awareness and income generating projects. In the main these 
are uncoordinated and remain inadequate for the needs of the 
country, but the work that so many people is doing has not 
stopped because of the current debates.
    The school-based program is being expanded and there are 
increasing interventions aimed at youth in both school and 
tertiary institutions as well as looking at ways to integrate 
youth not in school.
    The picture is very bleak at the moment, but as a 
discussion we hosted on behalf of the AAI showed last week, it 
is by no means hopeless, there is still time to turn the 
epidemic around, there is still time to make an enormous impact 
in prevention and care and still time to rethink the policies 
and programs, especially with regards to orphans and families 
and communities in distress and most at risk.
    But this requires new and creative vision, new ways of 
addressing the socioeconomic and political questions and a new 
understanding of what is possible in this epidemic and how best 
the society and country can hope to come through it.
    Durban 2000 did energize the country and it's important to 
sustain that momentum. There is a great deal of concern and 
this needs to be channeled into actions that really will make a 
difference rather than looking at more of the same.
    In conclusion, if I could just introduce the person who is 
on my right, who is, in fact, not Ken Yamashita, but is Dr. 
Ashraf Grimwood, who is the current chair of NACOSA (National 
AIDS Convention of South Africa), and physician of enormous 
experience in dealing with HIV/AIDS. Thank you.
    [The prepared statement of Ms. Crewe appears in the 
appendix.]
    Mr. Royce. Thank you, Mary. Thank you very much. Thank you 
for your thoughts there.
    Maybe I could ask you a question about the faith 
communities that are active in South Africa, the Christian 
community, Muslim community, Hindu communities and others 
there. Do they play a role in HIV/AIDS prevention, the 
activities in that regard, in South Africa?
    Ms. Crewe. I think that their role could be greater. They 
certainly do play a role, but I think that South Africa has a 
very difficult problem and that problem is the perception of 
the situation, or the reality of the situation, and the reality 
tends to get in the way of an effective campaign. So the 
prevention tends to ignore the reality, which is that we have a 
very high level of sexual activity among young people and a 
very high level of extramarital sexual activity, and I don't 
think that the faith organizations have really found a way to 
pass through that, but having said that, I think the faith-
based organizations are very strong in the provision of care 
and support.
    Mr. Royce. I see. Well, let me ask you another question 
that is perplexing, and that is on neighboring Botswana, which 
has, I believe, the highest rate of infection, 36 percent of 
adults; the worst hit country in Africa. Botswana is relatively 
prosperous and it has spent very little on HIV/AIDS programs. 
What has gone wrong in neighboring Botswana, in your view? Why 
has this situation developed there to such an extent?
    Ms. Crewe. Well, what I found fascinating about Botswana is 
in general denial, and that is the explanation that South 
Africa has given for its epidemic, which is that you need to 
have high levels of poverty, migration and internal conflict to 
have a high epidemic. Botswana would seem to suggest that you 
don't have to have those requirements. I think that for 
Botswana, and I confess to not having studied the epidemic in 
Botswana terribly closely, but my sense of Botswana is that it 
is a very small country, and that they believe that they were 
particularly not at risk of the epidemic and acted, as so many 
of our countries acted, too late. It is a very small country so 
the infection will spread very quickly, and I think it fits 
into the general denial that we have across South Africa. 
Uganda's response was exemplary. But I do believe that there is 
enormous denial, to a certain extent, of the epidemic.
    So by the time your national infection rate has reached 
more than 12 percent, in effect no matter what you do you are 
facing a crisis.
    Would you like to add to that?
    Dr. Grimwood. Well, I could say that the situation in 
Botswana has done a turn-a-round, and I think that there is 
immense government leadership. There is incredible focus on 
what needs to be done, and they have embarked upon several 
programs which would hopefully bring about positive impact in 
the next few years. So the feeling that I do get when I do 
travel and work in Botswana is that things are on the right 
track there.
    Mr. Royce. Another question I wanted to ask, and maybe I 
should direct this at Dr. Lamptey, but it is clear that, as we 
have said, some African leaders have been very aggressive in 
promoting prevention. Others have not, and President Moi of 
Kenya faces a situation now where 14 percent of adults, I 
believe, are HIV-positive. He did not endorse the use of 
condoms as a preventive method until I think it was December 
1999. Why was President Moi so reluctant to make this 
recognition? What holds back heads of state in terms of this 
issue of prevention, Dr. Lamptey?
    Mr. Lamptey. I think there are several factors, not only in 
the case of President Moi but other African leaders, including 
President Mugabe. One of them is probably pressure of religious 
leaders not to agree to the use of condoms, and in the case of 
Zimbabwe, part of the reason was because they were afraid that 
it would increase promiscuity among adolescents. This is a 
belief despite of what has been consistently shown, in studies, 
that the availability of condoms does not actually increase 
sexual activity among adolescents.
    In the case of Kenya also, I think, over the years has been 
the fear that some of these efforts will affect the tourist 
industry, which is an important economic base for Kenya. And so 
I think these are some of the major reasons. But for me there 
is no excuse for African leaders to sit on their hands and not 
act adequately enough to intervene in this epidemic.
    Mr. Royce. I thank you, Dr. Lamptey.
    We are now going to go to our Ranking Member, Mr. Don Payne 
from New Jersey.
    Mr. Payne. Thank you very much. Thank you both, all of you, 
for your testimony. As I indicated earlier, I do believe that 
it is slow in coming, but I recall early discussions with 
President Museveni of Uganda 7 or 8 years ago where he was at 
this same stage that we find, say, President Mugabe and some of 
the other presidents that had been slower in coming to 
realization that there had to be education, that it is 
something that is here, that it is something we have to deal 
with; prevention can be by distribution of condoms, things of 
that nature, something that no head of state wanted to get up 
and discuss, and other cabinet level people, but 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 
Colorado.
    Mr. Tancredo. Thank you, Mr. Chairman.
    Mr. Lamptey, your testimony, in your testimony you 
specifically cite the VCT programs, voluntary HIV counseling 
and testing, as having been successful in reducing high risk 
sexual behavior, improving access to health care and serving as 
an entry point for the prevention of MTCT. Specifically, could 
you tell me exactly what aspect--why is that true? What happens 
in a VCT program that you believe provides this kind of change 
of behavior?
    Mr. Lamptey. I believe that the people who return to STD 
services are people who already have been informed of what is 
hazardous behavior or believe that they may possibly be 
infected. So you have these people who you are attracting who 
believe that they may be at risk of HIV.
    Mr. Tancredo. So you have sub-selected.
    Mr. Lamptey. And then having been tested, if they are HIV-
positive, they realize that they need to change their behavior 
to protect not only their spouses and their casual partners, 
but also their families in the long run, and that's a message 
we give that even though you may be infected, it is still 
important to prevent your wife from getting infected and your 
subsequent children. For those who are uninfected, there is 
obviously relief, but at the same time, we emphasize the fact 
that you are lucky to have been unaffected at this time, but 
you need to change your behavior to make sure that you don't 
get infected in the future.
    And I think basically, going back to the other question of 
education, most people have adequate knowledge about how the 
HIV is transmitted. I think in most countries 70 to 80 percent 
of the population are aware of the causes of HIV and how it is 
transmitted. What they need are the skills to change behavior, 
the access to condoms, how to negotiate for sex, especially 
women, and also all the things they need to do to empower them 
to be able to make that change, the switch from high-risk 
behavior to low-risk behavior. And, these are some of the 
things that we impart during our voluntary counseling sessions.
    Mr. Tancredo. It is encouraging on the one hand that 
something is working. It is discouraging that it is only for 
those people who have already placed themselves in the position 
of having access, I guess, to that kind of help, but so it begs 
the question of course how do we address--what do we do about 
the larger population 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 
knowing it.
    So there's a sense of denial, and I agree with everything 
that was said before.
    Mr. Tancredo. Thank you. I think those observations are 
really cogent.
    Mr. Royce. Thank you. We will go now to Congresswoman Lee.
    Ms. Lee. Let me just thank both our panelists for their 
very profound testimonies and also just thank you for the work 
that you're doing. I know oftentimes being on the ground, 
especially with Mary and her colleague, can be, that can be 
overwhelming and oftentimes in the face of death and dying and 
pain and suffering 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 
strategies?
    And then let me just ask Mary, and you can think about this 
while Dr. Lamptey is responding: The orphan crisis is 
phenomenal, unbelievable, staggering, mind-boggling. I visited 
southern Africa with Sandy Thurman and a White House delegation 
year before last and I believe our findings and the report that 
we issued and the public awareness that we were able to present 
actually was somewhat useful in helping to begin to focus on 
this whole HIV-AIDS pandemic in sub-Saharan Africa, and I 
believe it was the orphan crisis that really initially captured 
the attention of many in our country.
    I was talking with a minister of health from one of the 
countries in southern Africa, and she made a suggestion, and 
you mentioned creative approaches to solving or beginning to 
solve some of the support issues around the orphan crisis. One 
of those suggestions was that children whose parents are dying 
of AIDS may--we may want to look at how to help put these 
children in villages and begin to develop the infrastructure of 
the village so that they are transitioned into a stronger 
extended family unit, and the transition then would be easier 
and sustained once their parents passed away and then the 
villages would be a stronger village because of the economic 
development and the poverty reduction and issues that had been 
taking place.
    This was a concept that I thought may make sense. I don't 
know if we have looked at any, and I would like to just ask you 
if you have seen any creative approaches in your work to the 
orphan crisis that really would help make--help these children 
live the kind of lives they deserve to live because I know the 
orphanages are under extreme duress because they don't have the 
resources to take care of 12 million children.
    So first, Dr. Lamptey, let me just ask you now.
    Mr. Lamptey. Thank you for your question. ``First 
generation surveillance'' took place in the early part of the 
epidemic and consisted of simply doing testing of selected 
population groups to give us an idea of what proportions of 
people were infected.
    We moved beyond that to what we call the ``second 
generation surveillance,'' which has a number of components. 
One, a systematic surveillance--serological surveillance of 
selected populations all over the country, including pregnant 
women, some high-risk groups like prostitutes, STD patients. 
That's the first component.
    The second component is also collecting behavior data that 
gives a good indication of how people are behaving. The problem 
with serological surveillance is that it takes several years to 
change because of the long incubation period. However, behavior 
can change very quickly, and even in the countries that have 
been successful, the only way you can be truly sure that the 
changes in surveillance are due to the interventions is to 
actually document that behaviors have changed. Serological 
surveillance can change because of an 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 
some extent.
    I think part of the problem lies in a lack of looking 
beyond the status quo. We always tend to ask status quo 
questions and we get status quo answers, and we have never 
really looked at the way in which we integrate the department 
of housing, of transport, of welfare and health and education 
to come together to develop one kind of solution, and I really 
do think we have to look at not removing children from the 
community. Very often putting children in extended families 
means that they move huge distances from where they grew up. I 
would support the idea of some kind of very careful community-
integrated institutional care and support, however, that 
looks--and I don't mean existing orphanages at all. But I 
really think we have to start challenging housing departments, 
architecture faculties, people to say we have to look after 
children for all kinds of ethical reasons, human rights 
reasons, security reasons and simply to secure our future, and 
if putting them into villages where you have key adults in 
certain positions, I think we have to experiment with that, and 
I am not meaning experimenting with children's lives at all, 
but failure to do that means that we are actually simply 
neglecting the children, and I think, assuming that there is an 
interest in southern Africa, that is actually neglecting the 
issue on the basis of what we believe is there.
    So I am unaware of any children's villages operating in 
South Africa at the response to the orphan crisis, and I think 
one could do very, very fascinating work in looking at new ways 
of housing of children and I think we also have to look at new 
families. We have to reconceptualize how we define families and 
what families are.
    Dr. Grimwood. May I make a comment on that? The issues do 
precede, though, the situation when you have an orphan problem 
because children of positive families are at risk, and as their 
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

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               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 
Reality.








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