[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
HIV/AIDS, TB, AND MALARIA: COMBATING A GLOBAL PANDEMIC
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
MARCH 20, 2003
__________
Serial No. 108-10
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
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COMMITTEE ON ENERGY AND COMMERCE
W.J. ``BILLY'' TAUZIN, Louisiana, Chairman
MICHAEL BILIRAKIS, Florida JOHN D. DINGELL, Michigan
JOE BARTON, Texas Ranking Member
FRED UPTON, Michigan HENRY A. WAXMAN, California
CLIFF STEARNS, Florida EDWARD J. MARKEY, Massachusetts
PAUL E. GILLMOR, Ohio RALPH M. HALL, Texas
JAMES C. GREENWOOD, Pennsylvania RICK BOUCHER, Virginia
CHRISTOPHER COX, California EDOLPHUS TOWNS, New York
NATHAN DEAL, Georgia FRANK PALLONE, Jr., New Jersey
RICHARD BURR, North Carolina SHERROD BROWN, Ohio
Vice Chairman BART GORDON, Tennessee
ED WHITFIELD, Kentucky PETER DEUTSCH, Florida
CHARLIE NORWOOD, Georgia BOBBY L. RUSH, Illinois
BARBARA CUBIN, Wyoming ANNA G. ESHOO, California
JOHN SHIMKUS, Illinois BART STUPAK, Michigan
HEATHER WILSON, New Mexico ELIOT L. ENGEL, New York
JOHN B. SHADEGG, Arizona ALBERT R. WYNN, Maryland
CHARLES W. ``CHIP'' PICKERING, GENE GREEN, Texas
Mississippi KAREN McCARTHY, Missouri
VITO FOSSELLA, New York TED STRICKLAND, Ohio
ROY BLUNT, Missouri DIANA DeGETTE, Colorado
STEVE BUYER, Indiana LOIS CAPPS, California
GEORGE RADANOVICH, California MICHAEL F. DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire CHRISTOPHER JOHN, Louisiana
JOSEPH R. PITTS, Pennsylvania JIM DAVIS, Florida
MARY BONO, California THOMAS H. ALLEN, Maine
GREG WALDEN, Oregon JANICE D. SCHAKOWSKY, Illinois
LEE TERRY, Nebraska HILDA L. SOLIS, California
ERNIE FLETCHER, Kentucky
MIKE FERGUSON, New Jersey
MIKE ROGERS, Michigan
DARRELL E. ISSA, California
C.L. ``BUTCH'' OTTER, Idaho
David V. Marventano, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Health
MICHAEL BILIRAKIS, Florida, Chairman
JOE BARTON, Texas SHERROD BROWN, Ohio
FRED UPTON, Michigan Ranking Member
JAMES C. GREENWOOD, Pennsylvania HENRY A. WAXMAN, California
NATHAN DEAL, Georgia RALPH M. HALL, Texas
RICHARD BURR, North Carolina EDOLPHUS TOWNS, New York
ED WHITFIELD, Kentucky FRANK PALLONE, Jr., New Jersey
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
Vice Chairman BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico GENE GREEN, Texas
JOHN B. SHADEGG, Arizona TED STRICKLAND, Ohio
CHARLES W. ``CHIP'' PICKERING, LOIS CAPPS, California
Mississippi BART GORDON, Tennessee
STEVE BUYER, Indiana DIANA DeGETTE, Colorado
JOSEPH R. PITTS, Pennsylvania CHRISTOPHER JOHN, Louisiana
ERNIE FLETCHER, Kentucky JOHN D. DINGELL, Michigan,
MIKE FERGUSON, New Jersey (Ex Officio)
MIKE ROGERS, Michigan
W.J. ``BILLY'' TAUZIN, Louisiana
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Allen, Hon. Claude, Deputy Secretary, Department of Health
and Human Services......................................... 8
Barry, Donna J., Partners in Health.......................... 35
Green, Edward C., Senior Research Scientist, Harvard Center
for Population and Development Studies..................... 45
Monico, Sophia Mukasa, Director, AIDS Program, Global Health
Council.................................................... 39
Smith, Shepherd, President and Founder, Institute for Youth
Development................................................ 32
Material submitted for the record by:
Barry, Donna J., Partners in Health, letter dated April 3,
2003, enclosing material for the record.................... 60
Green, Edward C., Senior Research Scientist, Harvard Center
for Population and Development Studies, response for the
record..................................................... 61
Monico, Sophia Mukasa, Director, AIDS Program, Global Health
Council, letter dated April 23, 2003, enclosing material
for the record............................................. 56
Alan Gutmacher Institute, letter dated March 20, 2003,
enclosing statement........................................ 55
Human Rights Watch, letter dated March 27, 2003, enclosing
material for the record.................................... 62
Smith, Shepherd, President and Founder, Institute for Youth
Development, letter dated April 14, 2003, enclosing
material for the record.................................... 59
(iii)
HIV/AIDS, TB, AND MALARIA: COMBATING A GLOBAL PANDEMIC
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THURSDAY, MARCH 20, 2003
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Health,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m., in
room 2322, Rayburn House Office Building, Hon. Michael
Bilirakis (chairman) presiding.
Members present: Representatives Bilirakis, Upton,
Greenwood, Wilson, Pitts, Ferguson, Brown, Waxman, Towns,
Green, Capps, and DeGette.
Also present: Representative Solis.
Staff present: Patrick Ronan, majority counsel; Steve
Tilton, health policy coordinator; Eugenia Edwards, legislative
clerk; John Ford, minority counsel; and Jessica McNiece,
minority staff assistant.
Mr. Bilirakis. I call this hearing to order. I'd like to
start off by taking a moment to thank all of our witnesses for
appearing before the subcommittee today. We certainly value
your expertise and we're grateful for your cooperation and
attendance.
Today's hearing will focus on the horrendous impact that
HIV/AIDS, tuberculosis and malaria are having in many parts of
the world, particularly in Africa. The numbers are certainly
staggering. Of the 42 million people estimated to be HIV
infected worldwide, approximately 37 million of them live in
Sub-Saharan Africa, China, India, Southeast Asia and Latin
America.
Although HIV rates are rising at a disturbing rate in many
of those countries, the area of the world most affected by this
scourge is Africa where nearly 30 million people are HIV
infected. An entire generation of Africans are endangered of
being decimated by the horrible, yet preventable disease.
We also face daunting challenges with respect to
tuberculosis and malaria where one-third of the global
population carries the virus that causes TB. There are over 8
million new cases of TB every year, with over 2 million deaths.
Over 80 percent of TB cases are found in 23 developing
countries.
The interaction between HIV/AIDS is particularly
frightening. HIV infected people are much more likely to
develop active TB. While TB, in turn, accelerates the onset of
AIDS in individuals infected with HIV.
Finally, malaria exacts a similarly gruesome toll in
underdeveloped nations. Malaria is the most common life
threatening infection in the world. It kills a child every 30
seconds and causes more than 1 million deaths and 500 million
infections annually. A full 90 percent of these deaths occur in
Sub-Saharan Africa where most of the victims are under 5 years
old.
Fortunately, there is hope. President Bush has affirmed the
need for the United States leadership in this critical area. As
we're all aware, the President pledged $10 billion in new
funding to combat AIDS, TB and malaria globally. In addition, I
am pleased that Secretary Thompson is chairman of the board of
the Global Fund to fight AIDS, tuberculosis and malaria. I'm
sure that with his leadership, the Fund will continue to
provide much needed resources to help developing nations fight
these terrible diseases.
I am looking forward to hearing the testimony from our
witnesses today. I think it's important that we learn about
which interventions have been helpful in controlling these
diseases and which ones have not, especially if we're going to
commit $10 million of taxpayers' funds to help control
infectious diseases in other countries.
We must ensure that whatever funds we dedicate to this
effort are used in the most effective manner and I intend to
assume that responsibility as the subcommittee moves forward in
its work.
While there are strong humanitarian justifications for our
level of involvement, we also have a compelling national
interest as well. I believe that the growth and development of
many of these nations is contingent on managing and ultimately
defeating a seemingly unchecked spread of these deadly
diseases.
With that, I yield to my friend from Ohio for an opening
statement. And again I would ask members of the subcommittee to
keep in mind if they would waive their opening statements, they
can have as much as 8 minutes questioning later on.
I yield to the gentleman from Ohio, Mr. Brown.
Mr. Brown. Thank you, Mr. Chairman. I want to welcome
Secretary Allen. Thank you for joining us again in our
Committee. I want to extend a special welcome to Donna Barry,
Director of the Russia program called Partners in Health which
is a Boston-based NGO which operates TB and HIV treatment
programs in the central plains of Haiti and Lima, Peru and in
Tomsk, a city in central Siberia and in Russia.
I traveled with Donna and her colleagues of Partners in
Health to visit Moscow's largest jail where hundreds of not yet
sentenced prisoners infected with tuberculosis are living in
small cells with little ventilation. There's a growing problem
of multi-drug resistance of so-called MDR-TB in Russian prisons
which comes from incorrect or interrupted treatment and
inadequate drug supplies. We then visited about a 5-hour flight
east to the city of Tomsk. I visited a Russian prison colony
Tomsk where only 6 years ago in a prison colony made up of
about 1,100, all inmates all infected with tuberculosis only 6
years ago, 65 or so inmates were dying a year to date. Last
year no one in that prison died of tuberculosis.
Yesterday, 1,100 people in India died of tuberculosis. In
January, in Sub-Saharan Africa, 225,000 people died from AIDS.
In 2002, as the chairman said, more than a million people in
the world died from malaria.
I want to talk this morning primarily about tuberculosis
and publicly thank Heather Wilson, my friend from Mexico, for
the work that she has done in tuberculosis, in combatting one
of the world's longest existing and terrible diseases.
The chairman said it infects one third of the world's
population, one third of the world's population carry the TB
bacteria. It's a leading killer of young men and young women
and people with HIV worldwide. HIV/AIDS and TB form a lethal
combination, each speeding the other's progress. HIV promotes
rapid progression of primary TB infection to active disease.
It's the most powerful known risk factor for reactivation of
latent TB infection to active disease.
HIV patients often die of TB before they succumb to AIDS.
We have effective treatment for TB and a mechanism to
provide low cost tuberculosis drugs. The drugs required for
treating standard TB cost as little as $10 for a 6-month
regimen in developing countries. Access to these life saving
treatments means kids are not pulled out of school to work or
care for a sick parent. It means an HIV positive father in the
developing world has a few more years of life to provide for
his family.
What AIDS and TB experts know, but policymakers
consistently under estimate is that preventing and treating
AIDS without preventing and treating TB is a virtual death
sentence of the developing world. If AIDS doesn't kill you, TB
will.
The President said he's committed to spending $10 billion
new dollars for preventing and treating HIV/AIDS worldwide.
Unfortunately, only a fraction of that $1 billion will go to
one of the best, most results oriented, easiest to quantify
mechanisms available for treating these three killers, the
Global Fund to fight AIDS, TB and malaria and I join in the
chairman's comments in optimism that Secretary Thompson will
chair the Global Fund in the year ahead.
The Global Fund has hired independent accounting firms to
oversee distribution of funds. It has the single best reporting
mechanism of any other international aid program. It will
require quarterly reporting on outcomes, disperse funds based
on results, and if they don't see quantifiable positive
results, we'll pull the funding after 2 years and spend it
elsewhere.
By the end of 2005, the Fund will show the number of
medical trained personnel, patients treated and in case of TB,
the number of patients cured. USAID has failed to do that in
numerous meetings and requests and reporting from that agency.
The President's initiative is aimed, unfortunately, at only
14 countries; 12 Sub-Saharan African countries and Guyana and
Haiti in our hemisphere. With the devastation, while greatest
in those countries, the problems in most of the rest of the
world are even more important because that's where most of the
rest of the world lives. The White House plan excludes India,
China, Bangladesh, Brazil, Mexico, Pakistan, Indonesia, the
countries where literally half the world's population lives and
where most of the problems for TB and malaria reside. It
excludes 15 of the 22 high-burden TB countries which account
for 80 percent of the world's TB population. Despite the
President's intentions investing sufficiently in 85 to 100
countries will turn the tide of AIDS. Investing in only 14
countries will make in the words of the Executive Director of
the Global Fund, will make only ``a minor dent.'' This
committee must consider the role of CDC also in addressing this
global pandemic. CDC has extensive knowledge and expertise
implementing programs that treat malaria and TB and HIV/AIDS.
CDC staff provide technical and scientific support for
international agencies like USAID and provide support for
national infectious disease programs in developing countries.
CDC is driven helping countries implement a strategy
specific to and appropriate for each country as the Global Fund
will do, not a one size fits all in Christian Brazil and Muslim
Bangladesh. It will reduce the incidence of deadly infections.
CDC recognizes what's outside our borders can easily travel
into the U.S., a business woman returning from Russia or a
family of tourists returning from India or Africa. Despite
CDC's expertise in infectious disease, they're handicapped by
Congress' decision to funnel majority of international aid
through USAID. CDC has a relatively small budget for the
international AIDS program and their work international TB
control is almost entirely funded by----
Mr. Bilirakis. Please sum up, if you will.
Mr. Brown. Fifteen more seconds. We can say, Mr. Chairman,
without exaggeration that unless we take unprecedented dramatic
action to both prevent further spread and to treat all those
who require treatment that AIDS, TB and malaria will take a
much greater social, political and economic toll than did the
Great Plague.
Mr. Bilirakis. The chair thanks the gentleman. Mr. Upton
for an opening statement.
Mr. Upton. Thank you, Mr. Chairman. I'll be very, very
brief. I want to insert my record fully into the record, my
statement into the record.
Mr. Chairman, the statistics are indeed staggering and
unsafe injection practices such as the widespread reuse of
syringes designed for a single use only have been linked to the
transmission of many of these diseases. In the last Congress, I
introduced legislation that embodied a four-pronged approach to
improving injection practices. Now we strengthened the
procedures for proper needle and syringe disposal. We promoted
the availability and use of needles and syringes that could not
be re-used. I look forward to working with you on this
legislation again in this Congress and I would hope that we
could get this passed again in the House as we did last year.
I yield back the balance of my time.
Mr. Bilirakis. The chair thanks the gentleman and of
course, without objection, the opening statement of all members
of the subcommittee will be made a part of the record.
Ms. Capps for an opening statement.
Ms. Capps. Thank you, Mr. Chairman. I appreciate your
providing this opportunity to examine the very important issue
of global AIDS and its terrible toll. I appreciate our
witnesses who are here today.
I was pleased to hear the President make a commitment to
ending HIV/AIDS, particularly in Africa. It is commendable, but
we have to make sure that the funds he has committed are used
properly. No continent has been more devastated by HIV/AIDS
than Africa. Sub-Saharan Africa is home to 29.4 million people
living with HIV/AIDS. This has been referenced already last
year. There were 3.5 million new infections.
But in some places, progress is being made. For example,
Uganda. Several organizations including U.N. AIDS and the World
Health Organization have touted Uganda's success because they
have been able to decrease HIV/AIDS rates. In the late 1980's,
Uganda suffered from an HIV/AIDS rate of nearly 30 percent. By
the 1990's, the prevalence was down to 10.5 percent. Now it is
close to 5 percent. Uganda's programs have proven effective in
combatting HIV/AIDS, particularly the ABC program is a
comprehensive one that does work. It touts the principles of
abstinence, be faithful and condom use all together and has
been very effective. What makes this program so successful is
its integrated and community-based approach. Reports from USAID
and U.N. AIDS indicates that comprehensive and community-based
approach to HIV/AIDS prevention works best.
The fundamental goal of these public health interventions
is to change behavior and it appears that Uganda's use of
integrated behavioral changed programs has had remarkable
success. There is also no evidence that abstinence works alone.
There is no data that sufficiently reports abstinence only
rhetoric as causally decreasing rates of HIV/AIDS in Africa.
To remain global leaders in the area of HIV/AIDS
prevention, we must promote comprehensive prevention programs.
Science is our best guide in these efforts. We cannot allow
ideological beliefs and fears to undermine the health of
nations.
But I fear that restrictions based on ideology will be
attached to the Global Funds we provide. For the past 2 years,
the Bush administration has been trying to do just that,
putting us in league with countries like Syria, Libya, Sudan,
Iran and even Iraq. By making funding contingent by following
an abstinence only criterion, we do such a great disservice to
our global partners and undercut efforts to prevent the spread
of AIDS.
With our scientific and health expertise, we have an
obligation to get this right. And I believe we have an
obligation to work with local communities according to the
values and systems that they have found to be effective an that
they support.
In these times, we should not try to be viewed as partners
working with countries. We should try to be viewed as partners
working with countries, not as outsiders imposing our will on
them. We should defer to the experts who repeatedly tell us
that fundamental public health approaches must be all
encompassing and based on science.
I look forward to hearing from the witnesses today. I hope
we can put aside ideology and truly make progress on this
critical issue.
I yield back the balance of my time.
Mr. Bilirakis. The chair thanks the gentle lady. The gentle
lady from New Mexico, Ms. Wilson.
Ms. Wilson. Thank you, Mr. Chairman. I appreciate your
having this hearing today. As my colleague from Ohio mentioned,
this is an issue of particular importance to me and I look
forward to working with him, particularly on the problem of
tuberculosis.
The city of Albuquerque in the State of New Mexico has a
long history and connection to the treatment of tuberculosis.
In 1903, the first people starting coming to the high desert of
New Mexico with its perpetual sunshine and its high, dry
climate to treat tuberculosis. In 1912, when New Mexico became
a state, the city of Albuquerque's population was one-third
active tuberculosis cases. That's a huge number. Next week, in
Las Cruces, New Mexico, we are going to be launching a bi-
national effort between the United States and Mexico to combat
tuberculosis on both sides of the border. So it is steeped in
our history, but I think it also represents part of our future.
The No. 1 leading cause of avoidable death in the world is
tuberculosis. In poor countries, it's estimated to cost the
world about $12 billion a year. And a lot of it is the
connection between tuberculosis and HIV. It's a lethal
combination and 15 percent of AIDS deaths are caused by
tuberculosis. It's one of the things that can be successfully
treated among HIV positive people.
Disease knows no borders, geographic or political. And
tuberculosis is arriving in America. Most of the cases in
America, 60 percent of the cases, are actually among foreign-
born people. So if we want to eradicate tuberculosis in the
United States, it must be an international effort. And we have
the capacity to eradicate TB. It is within the realm of
possibility if we put the effort behind it.
Perhaps most frightening about tuberculosis is the
emergence of more and more drug resistant strains of TB. Not
only those that are multidrug resistant to five or more drugs,
but those that are resistant to even antibiotics become
problematic for treatment and much more expensive.
I believe that the eradication of tuberculosis must be an
international effort that if we focus on the eradication and
treatment of tuberculosis, we will be directly addressing the
leading cause of death among those who are HIV positive and
that it has tremendous public health benefits here in the
United States as well and that's particularly true in border
states like my own.
Mr. Chairman, thank you for focusing on this issue. I
appreciate your holding this hearing.
Mr. Bilirakis. The chair thanks the gentle lady.
Mr. Towns for an opening statement.
Mr. Towns. Thank you very much, Mr. Chairman, for holding
this hearing today. I want to thank our distinguished witnesses
for testifying today on the global HIV/AIDS pandemic.
Today, the International Relations Committee is scheduled
to mark up a bill in response to HIV/AIDS. Despite the great
efforts of my colleague on that committee, I believe that the
nature and enormity of the AIDS problem leaves room for the
contribution and expertise of this Committee.
Mr. Chairman, first we must get a firm grasp on the
enormity of the problem. AIDS is truly a global killer. The
virus respects no national boundaries, no religious
affiliation, no race, no gender and no age. In Sub-Saharan
Africa, the region of the world most severely affected by HIV
and AIDS, there are an estimated 25 million persons infected
with the virus. In 7 African countries, 20 percent of the
population is affected. In Botswana, it is estimated that 36
percent of the adult population is infected with HIV.
Other regions of the world have equally alarming
statistics. In Asia, the world's most populous continent, 3.5
million people are infected with HIV. Eastern Europe has the
most rapid rate of growth in HIV infections. In 20 short
months, the number of infected persons in the Russian
federation rose from 10,000 to 70,000. That is astonishing. In
North America, it is estimated over 900,000 people are infected
with HIV. In Latin America, an estimated 1.9 million people are
infected. In the Caribbean, it has impacted about 400,000
people.
HIV/AIDS is the leading cause of death in Africa and the
fourth leading cause of death worldwide. In the countries most
affected in Africa, the life expectancy has declined by 10
years and infant death rates have doubled.
This disease has ravaged families. The loss of one parent
can lead to the loss of income, the end of educational
opportunities for children and increase child labor. The laws
of both parents can be devastated. It has been estimated that
by 2010 there will be 40 million children in African who have
been orphaned because of the AIDS virus.
Mr. Chairman, that is the equivalent to every child living
east of the Mississippi River in this country.
Additionally, the huge number of deaths have caused
hardships on social systems, national growth, economic
development because those most likely to be affected are adults
under 50. This kind of internal disruption may cause political
instability and ultimately pose a national security risk.
Mr. Chairman, there is a real life and death need for
assistance and we cannot turn away. We cannot content ourselves
with notions that somebody, somewhere at some point or some
time would do something about it. Compassion and concern are
not enough. We must resolve that we will take concrete action
here and now. The massive expansion of HIV is not inevitable.
This epidemic can be stabilized and reversed. Successful
programs include strong, high level political leadership----
Mr. Bilirakis. The gentleman's time has long expired. Will
you please summarize.
Mr. Towns. I will definitely be delighted to, Mr. Chairman,
because you allow me to be included in the record, right?
Mr. Bilirakis. I will allow you to.
Mr. Towns. The national program plan adequate funding and
strong involvement. We must work effectively with leaders of
the world to achieve these outcomes. We must resolve to act
now, not later.
Mr. Chairman, thank you very much for allowing me to go
over.
Mr. Bilirakis. By all means. Ms. Solis is not a member of
the subcommittee, but courtesy certainly to her. You're welcome
here and please proceed with your opening statement.
Ms. Solis. Thank you. Thank you very much, Mr. Chairman,
and also I'd like to thank the Ranking Member, Congressman
Brown for allowing me the opportunity to be here to share with
you just a few thoughts. I know we have a call right now to go
vote, but my concern is obviously the whole issue of addressing
AIDS throughout the entire world, particularly, our lack of
diligence and focusing in Latin America and in Central America.
As one of the only Members of Congress who is a Central
American or partly through a parent, I find that it's rather
distressing that we're not focusing on the effects there of HIV
and AIDS, but also malaria and particularly in Central America
with respect to Nicaragua. I had a recent visit there last year
and found that there is a lot of movement with respect to
people leaving the rural areas to the inner cities there, and
finding that instead of capping this whole disease of malaria
that it's actually on the rise. And would hope that we would
extend some thought and perhaps research in that area.
My other concern is that we're neglecting areas like in
Mexico where we have 51,000 or more cases of HIV and AIDS;
28,000 that are reported in Central America.
We have something here. We have learned lessons from the
past. We should be focusing in on those other areas that need
much attention.
I would ask unanimous consent, Mr. Chairman, to submit my
further testimony for the record.
Mr. Bilirakis. Without objection, that will be the case.
Ms. Solis. Thank you.
Mr. Bilirakis. All opening statements are vended. Panel One
consists of the Honorable Claude Allen, Deputy Secretary of the
Department of HHS.
Mr. Secretary, you're more than welcome here. Thank you for
taking time to be here at our invitation, of course. I'm going
to ask you to start your opening statement, sir, but then I
will have to rudely interrupt you.
Mr. Brown. Mr. Chairman, I ask unanimous consent to put the
statement of Mr. Waxman in and something from the Allen-Lugar
Institute.
Mr. Bilirakis. Without objection, that will be the case.
And when we break, I really don't have any idea of the
time. I'm probably going to say we'll break in an hour, but it
may be a little longer. I just don't really know what to tell
you. I apologize, but unfortunately, that's the way things are.
Mr. Allen, that's the 10-minute bell. Start for maybe 1
minute, that way I know that we've terminated the opening
statements.
You can go for 1 minute, if you would, and then if you
would maybe defer.
STATEMENT OF HON. CLAUDE A. ALLEN, DEPUTY SECRETARY, DEPARTMENT
OF HEALTH AND HUMAN SERVICES
Mr. Allen. Thank you, Mr. Chairman and members of the
subcommittee for giving the Department of Health and Human
Services this opportunity to talk with you this morning about
the global response to HIV, tuberculosis and malaria. This is a
subject that is very personal to the President, Secretary
Thompson and all of us at the Department. The United States is
a blessed Nation and the President has called upon us to
provide hope to millions upon millions of people around the
world who are suffering from HIV, tuberculosis and malaria.
When the President announced his emergency plan for AIDS
relief at the end of January he said it is, ``a step toward
showing the world the great compassion of a great country.''
And ``a work of mercy.''
Indeed, the President's $15 billion plan will prevent 7
million new HIV infections, treat 2 million HIV infected people
with antiretroviral drugs and care for 10 million HIV infected
individuals and AIDS orphans.
This initiative will virtually triple our commitment to
international HIV/AIDS assistance in 14 countries in Africa and
the Caribbean, the two areas of the world that are being
devastated by this disease right now.
The President's plan follows on the heels of his new
mother-to-child transmission prevention effort or the PMTCP
Program which he announced last year.
Mr. Bilirakis. Mr. Allen, it might be a good idea before
you get into the President's plan that we interrupt you halfway
through it if you could just cut at this point and I've
discussed this with Mr. Brown and we have probably at least a
half hour or so on these votes.
I'm going to say noon to come back. Again, I apologize to
you. So many of you have come such a long way.
Mr. Allen. That is not a problem, Mr. Chairman. I'd be glad
to do so.
Mr. Bilirakis. Thank you. So I'm going to recess now until
noon.
Mr. Allen. Thank you.
[Brief recess.]
Mr. Bilirakis. I think we should get started. Mr.
Secretary, you started, I think, to go into the President's
plan, so to speak.
Mr. Allen. Thank you again, Mr. Chairman. The President's
plan follows on the heels of his new Mother to Child
Transmission Prevention effort or PMTCT which he announced last
year. The PMTCT initiative is a strong model of good government
and demonstrates how quickly the United States can get much
needed resources out the door through our bilateral mechanisms.
HHS, the State Department and the United States Agency for
International Development have all worked cooperatively with
the White House Office on National AIDS Policy to ensure that
the PMTCT program pools all of the resources the U.S.
Government has to offer to countries desperate to prevent
children from coming into this world HIV positive.
The PMTCT initiative is a part of our overall Global AIDS
Program or GAP program. We work directly with 25 countries in
Africa, Asia, Latin America and the Caribbean to prevent new
infections, provide care and treatment to those already
infected and develop the capacity and infrastructure needed to
support these programs.
We calculate that these 25 countries account for 90
percent, for more than 90 percent of the world's AIDS burden.
For this fiscal year, the budget for Global AIDS Program is
$144 million plus $40 million for the PMTCT initiative.
I met earlier this week with my counterpart from Cambodia,
for example, which is at one of our GAP countries and they're
doing extraordinary work with our assistance on the ground. The
President's Emergency Plan for AIDS Relief includes both a
pledge of support for a dramatic increase in our bilateral
assistance and a multi-year commitment to the Global Fund to
fight HIV/AIDS, tuberculosis and malaria.
As you know, Secretary Thompson is now the Chairman of the
Global Fund. The Secretary and I hope that the President's
commitment to HIV/AIDS will encourage other donor countries and
the private sector to partner with us by increasing their
bilateral assistance to countries where they are present in
addition to making contributions to the Global Fund.
We are concerned right now about the fund's ability to
finance a third round of proposals. And Secretary Thompson is
uncomfortable with the current ratio of donations. The United
States should not be responsible for 50 percent of the total
pledges as is now the case. The U.S. commitment for fiscal year
2003 alone is 45 percent of what the Global Fund expects to
receive. This does not reflect adequately the vision of a true
public/private partnership for the Global Fund that the
President and the United Nations Secretary General Kofi Annan
outlined in the Rose Garden in May of 2001.
Secretary Thompson met with Secretary General Annan last
week and asked him to help leverage additional funds among the
donor countries, especially in Europe. The Secretary offered to
coordinate technical assistance for the fund, to aid the fund's
projects and applications as well.
Secretary Thompson is committed to doing all he can to
ensure that the fund has adequate resources and function in
accordance with the vision of the President and the wishes of
Congress, and provides funds to programs and services that will
improve and save the lives of those living with this disease.
We must never forget how important the component research
is in the fight of HIV/AIDS, tuberculosis and malaria. In
fiscal year 2003, the National Institutes of Health will devote
$251 million for AIDS related international research.
We're working here in the United States and around the
world to develop laboratory capacity, train scientists and help
nations develop prevention and treatment research agendas to
deal with these diseases. We're working aggressively also to
develop clinical research and trials for HIV/AIDS vaccines. And
while we have made tremendous progress in this area, we are
still years away from a vaccine. This is why we have to focus
our attention on prevention, care and treatment.
As we discuss international programs for prevention, it is
important that we, as Americans, do not export our own ideas,
but rather allow the countries we aid to develop prevention
methods and treatment programs that are sensitive to their own
cultures.
I know you will be hearing later this morning about Uganda
and their success use of the ABC program of prevention. The A
is for abstinence in young people. The B is for being faithful
in mutually monogamous relationships. And the C is for condom
use in high risk populations with the knowledge that condoms
are highly effective in preventing HIV infection and gonorrhea
in men, but not as effective with all sexually transmitted
diseases.
I have traveled to Uganda and I have seen that ABC is
working. Uganda is not the only country in Africa with an
increasing rate of life expectancy. It is indeed the single
country in Africa whose life expectancy has increased.
The ABC prevention concept is something that we need to
look at very seriously in our own country as well.
Unfortunately, I have been to other countries in Africa where
the outlook is not very positive. I have been into remote
village in Swaziland where a young woman lay dying on the cold
ground of her hut in the final stages of AIDS while her
children were outside being cared for by their grandmother or
her mother. It is predicted that Swaziland will have over
100,000 orphans in the next 5 years and the country now has the
highest rate of HIV/AIDS in the world.
I have been to South Africa and to Namibia and seen
children who were orphaned by parents who died of AIDS and many
of them are living with AIDS. I have been in Ethiopia where
I've been able to administer life saving polio vaccines to
infants and I've seen desperate medical personnel in all of
these countries looking for support and technical assistance in
fighting HIV/AIDS, tuberculosis and malaria.
Mr. Chairman and members of the subcommittee, we have a
real opportunity to effect change in the world with the
President's new initiative. The administration is ready to work
with you and to put together a bill that we can all be proud of
and Secretary Thompson and I look forward to making sure that
this is a reality.
I want to thank you again for allowing me to be here with
you this morning and I'm happy to answer any questions that you
may have at this time.
[The prepared statement of Hon. Claude A. Allen follows:]
Prepared Statement of Hon. Claude A. Allen, Deputy Secretary,
Department of Health and Human Services
Mr. Chairman and Members of the Subcommittee, I am Claude A. Allen,
Deputy Secretary of the U. S. Department of Health and Human Services.
I am pleased to be here today to provide an overview of the Department
of Health and Human Services' activities to combat the global spread of
HIV/AIDS, tuberculosis (TB) and Malaria. I bring greetings from
Secretary Thompson, and his thanks, as well, for your tireless efforts
to address these worldwide pandemics.
At the outset, I would like to acknowledge that we at HHS are in
your debt, Mr. Chairman, and in the debt of your colleagues on this
Committee, and others in this Chamber, for your support of prevention,
care and treatment of these diseases. The leadership of this Committee
has been crucial to the U.S. Government's response to this devastating
disease, and will continue to be, as Congress and the Administration
work together to support the Global Fund for AIDS, TB and Malaria,
implement the President's Emergency Plan for AIDS Relief, announced in
the State of the Union in January, and implement his international
Mother and Child HIV Prevention Initiative, announced last summer. The
broad bipartisan support that both these initiatives enjoy--as well as
the strong public support--speaks to their vital importance. I look
forward to continuing to work with each of you to make them reality.
The United States has a long history of assisting other countries
in need. And I am proud to report that the Department of Health and
Human Services is continuing that humanitarian tradition in a variety
of ways, but most particularly in helping developing countries address
the devastation caused by AIDS, TB and malaria.
From Tanzania to Vietnam to Haiti, HHS employees are on the ground,
working with Ministries of Health, nongovernmental organizations,
faith-based groups, and--equally important--with other U.S. government
entities, such as the State Department and the U.S. Agency for
International Development (USAID), to develop country-specific
solutions to the ravages of AIDS. Together with USAID, we are working
with 16 countries and with international organizations such as the
World Health Organization to address TB--which infects nearly eight
million persons per year. Worldwide, TB kills two million people each
year and is the cause of death for one-third of persons infected with
HIV. Further, we work with the World Health Organization (WHO) and
other partners to address malaria, which kills an estimated one million
children in the developing world each year.
Today, I will provide you with an overview of HHS activities and, I
hope, reinforce your long-standing, demonstrated commitment to U.S.
support in this essential endeavor.
Three HHS operating divisions are most actively involved in
fighting AIDS worldwide. The National Institutes of Health has a strong
portfolio of basic research in the areas of HIV and TB, including vital
efforts to develop a vaccine to prevent HIV infection and new treatment
technologies and strategies. NIH also trains U.S. and foreign
scientists as a critical part of its mission. The Centers for Disease
Control and Prevention (CDC) has engaged in international applied AIDS
research and programmatic efforts since the beginning of the pandemic
and supports bilateral and multilateral efforts to address TB and
malaria. And the Health Resources and Services Administration (HRSA),
through a cooperative agreement with CDC, works to train health care
workers internationally to care for people living with HIV and AIDS.
While there is not time today to go over all that we do to address
HIV, TB and malaria, permit me to briefly illustrate how, at HHS, the
pieces fit together into a strategic plan to combat AIDS around the
globe.
Research on AIDS
Guiding principles for the National Institutes of Health's global
research are to:
1. Target research efforts to develop prevention and therapeutic
strategies adapted for the unique needs of developing
countries;
2. Develop multidisciplinary research programs on AIDS and on malaria
and tuberculosis;
3. Build and sustain research capacity in developing countries;
4. Stimulate scientific collaboration and global, multi-sector
partnerships; and
5. Work with scientists in countries hardest hit to develop training,
communication, and outreach programs.
The United States has been the world's leader in research and
practical assistance to battle HIV/AIDS, and NIH's budget confirms that
commitment. In fiscal year 2003, NIH will devote over $2.7 billion on
AIDS research, with over $250 million to be spent on AIDS research and
training efforts abroad.
To conduct clinical research on vaccines for HIV/AIDS, the NIH
supports the HIV Vaccine Trials Network--or HVTN--a network of 16
domestic and 13 international sites. Directly and through
collaborations with investigators, mostly university-based, worldwide,
the HVTN also supports laboratory research worldwide to ensure that
vaccines are efficacious against a variety of HIV strains found around
the world. The HVTN currently is conducting a phase II clinical trial
in Haiti, Brazil, and Trinidad/Tobago. HVTN is working with the CDC in
several countries, to identify cohorts of populations at risk for HIV
infection and build the infrastructure necessary around the world to
conduct large-scale efficacy trials of potential vaccine candidates
when they become available.
NIH supports a growing portfolio of university-based biomedical and
behavioral research for the discovery, development, preclinical
testing, and clinical evaluation of interventions to prevent HIV
transmission, slow disease progression, and limit disease mortality.
NIH-sponsored programs target studies in Africa, Asia, Latin America
and the Caribbean on factors related to HIV transmission and the
mechanisms associated with HIV disease progression. The HIV Prevention
Trials Network--or HPTN--is a worldwide collaborative network designed
to conduct research in 16 international and nine domestic sites on
promising and innovative biomedical/behavioral strategies for the
prevention or reduction of HIV transmission among at-risk adult and
infant populations.
A critical element of NIH's research portfolio is efforts to
strengthen--or create--the research infrastructure of developing
countries as well as the capacity of in-country investigators to
conduct clinical trials of therapeutic and preventive therapies. These
therapies include treatment for opportunistic infections, such as TB,
which kills a large proportion of AIDS patients in the developing
world; AIDS vaccines; microbicides, and interventions to prevent
mother-to-child transmission.
Capacity-building for international research is a critical issue in
all the countries where NIH funds research activities. NIH focuses its
efforts in three essential areas:
Training Research Scientists--It is critical to the success of
international studies that foreign scientists be full and equal
partners in the design and conduct of collaborative studies. To
help build capacity in developing countries, NIH, through the
Fogarty International Center, funds the AIDS International
Training and Research Program (AITRP). The AITRP provides
research training to foreign scientists through grants to U.S.
universities. The program has provided training in the U.S. for
scientists from developing countries in Africa, Asia, Latin
America and the Caribbean, 85 percent of whom return home, and
training courses have been conducted in 60 countries. Over 200
senior investigators and health officials in Africa have been
trained through the AITRP, and thousands at more junior levels.
With 85% of trainees returning home, the AITRP is a model of
capacity building. It is no wonder that Dr. Salim Abdool-Karim,
Deputy Vice Chancellor for Research and Development at the
University of Natal in South Africa, and Principal Investigator
of a highly successful Fogarty AITRP grant has described this
program as the pre-eminent model of capacity-building for
developing countries.
Laboratory Capacity--NIH-supported HIV-related research helps
to build laboratory capacity in developing countries, where the
research is conducted, through purchase of laboratory equipment
and transfer of research technology.
Comprehensive International Program of Research on AIDS
(CIPRA)--NIH has launched CIPRA to provide long-term support to
developing countries to plan and implement a comprehensive HIV/
AIDS prevention and treatment research agenda relevant to their
populations, and to enhance the infrastructure necessary to
conduct such research. Through this initiative, funding will be
provided directly to foreign institutions for HIV research that
is relevant to the host country.
A safe and effective HIV preventive vaccine is essential to
controlling the AIDS pandemic. But, while we have made tremendous
progress in vaccine development, the deployment of a vaccine is likely
years away. Other biomedical interventions, such as microbicides, are
likewise not yet proven or ready for widespread use.
In the interim, the world's best--and only--hope for controlling
the epidemic is through sound prevention programs. And care and
treatment programs are essential to helping the millions already
infected to diminish the likelihood of infecting their partners,
furthering the aims of prevention and helping to keep productive
workers and citizens alive.
I will now discuss some of the prevention, care, and treatment work
HHS staff are performing in countries hardest hit by this terrible
disease. HHS scientists, public health experts, and specialists in AIDS
care and treatment form a critical component of the U.S. Government's
inter-agency response to the international HIV/AIDS pandemic.
Prevention, Care and Treatment
Through the HHS Global AIDS Program, CDC works directly with 25
countries in Africa, Asia, Latin America, and the Caribbean to prevent
new infections, provide care and treatment to those already infected
and develop the capacity and infrastructure needed to support these
programs. We calculate that these 25 countries account for more than 90
percent of the world's AIDS burden, based on prevalence estimates
released at the end of last year by the WHO and UNAIDS. Targeting our
resources to those countries most in need makes sense, and allows us to
achieve the greatest results for our modest investment. For this fiscal
year, the budget for the Global AIDS Program is $144 million, plus $40
million directed by Congress to the President's international Mother
and Child HIV Prevention Initiative, jointly managed by HHS and USAID.
In addition, CDC supports approximately $11 million in applied
prevention research to support these programs.
CDC's highly trained physicians, epidemiologists--who have special
training in the causes, distribution and control of disease in
populations--virologists and other laboratory scientists, and public
health advisors--who are experts in the science and practice of
protecting and improving the health of a community through a variety of
measures, including preventive medicine, health education, disease
control, refugee health, and sanitation, for example--are providing
technical assistance to host-country governments and others working to
prevent and control HIV/AIDS.
CDC staff are often located directly in host-country Ministries of
Health or their affiliated National AIDS Control Programs. Working in
close proximity with public health and medical colleagues fro both
government and non-governmental organizations allows CDC experts to
enhance their services to host-country programs. They are also co-
located with USAID colleagues, promoting complementary programming
between the two agencies.
In addition to CDC employees, the HHS Global AIDS Program currently
has nearly 400 locally employed staff, who serve in a range of
capacities, from research scientists, laboratory technicians, nurses
and midwives to computer specialists, statisticians, sociologists and
support staff. One of the primary goals of the HHS Global AIDS Program
is to develop in-country capacity to address HIV/AIDS. Local staff are
employed to form a national cadre of trained professionals who can
share their knowledge with others, developing an ever-growing nucleus
of trained personnel.
The Global AIDS Program was first funded in fiscal year 2000. It
builds on HHS's long and successful history of global initiatives to
promote health, in areas such as immunization. For example, in
Thailand, CDC staff worked with the Thai government to develop a
national mother-to-child HIV prevention program, the first of its kind
in the developing world. As a result of this effort, testing has been
implemented in all public hospitals and it is estimated that perinatal
transmission has been reduced to less than 10 percent preventing more
than 1,000 HIV infections in children each year.
All of this work now forms the foundation for HHS support for and
involvement in the President's Emergency Plan, which is focused on 14
of the hardest-hit nations, accounting for 50 percent of all HIV
infections. This five-year plan is expected to prevent seven million
new infections--60 percent of the projected new infections in the
targeted countries. Two million HIV-infected people will be treated
with anti-retrovirals and care will be provided to 10 million HIV-
infected individuals and AIDS orphans. Implementation will be based on
a ``network model'' being employed in countries such as Uganda: a
layered network of central medical centers that support satellite
centers and mobile units, with varying levels of medical expertise as
treatment moves from urban to rural communities. The model will employ
uniform prevention, care, and treatment protocols and prepared
medication packs for ease of drug administration. It will build
directly on clinics, sites, and programs established through USAID,
HHS, non-governmental organizations, faith-based groups, and willing
host governments.
Although the President's Emergency Relief Plan will not begin until
next fiscal year, the first stage of this unprecedented effort is his
Mother and Child HIV Prevention Initiative, which has already begun in
the same 14 countries and jointly administered by HHS and USAID. HHS
and USAID staff have now prepared develop preliminary country-specific
plans of action to target one million women annually, provide them with
HIV counseling and voluntary testing, essential prenatal care and
support services and--most importantly--with the life-saving drugs that
will help their babies be born free of HIV infection. We expect that
this initiative will reduce mother-to-child HIV transmission by 40
percent among the women treated. A second goal of the initiative is to
improve health care systems to provide care and treatment not only to
mothers and babies, but to fathers, other children and the broader
community as well. Strengthening health care systems is essential to
the success of the President's broader Emergency Relief Plan.
HRSA is lending its strength to this initiative through the
training of health care providers and the facilitation of partnerships
between U.S. hospitals and clinics and their counterparts in the 14
countries (``twinning'').
The President's Emergency Plan also increased our pledge to the
Global Fund to Fight AIDS, Tuberculosis and Malaria to $1.65 billion,
50 percent of the total $3.36 billion pledged to date. Our fiscal year
2003 commitment alone accounts for 45 percent of all resources
available to the Fund this year ($350 million of a total $780 million
pledged or in the bank), and the U.S. is responsible for 37 percent of
the Fund's cash on hand. With the exception of Germany and Ireland,
major donor countries have not increased their initial pledges, which
in most cases extend over several years. Secretary Thompson, who was
elected to serve a one year term as Board Chair during the last Global
Fund Board meeting in January, is committed to mobilizing additional
resources from both donor nations and the private sector. The U.S.
strongly supported creation of the Global Fund and continues to support
its efforts through technical assistance to partnerships as they
develop proposals for the Fund and helping to implement and monitor
Global Fund financed programs.
HRSA is lending its strength in the training of health care
providers to this initiative, and, more broadly, to HIV/AIDS programs
internationally.
For too long, people in the developing world have seen a diagnosis
of HIV infection as a death sentence. And it has been. But with the
promise of care and treatment, HIV need no longer mean a slow and
agonizing death. Parents no longer need dread leaving their children
orphaned and at risk themselves for HIV. For the first time, learning
your HIV status can be seen as a stepping stone to needed care. An HIV
test is the gateway to services. For those who are infected, they will
be able to receive treatment--and essential prevention and support
services to keep from transmitting the virus to others. For those who
are not infected, they can receive vital prevention services to learn
how to remain HIV-free, emphasizing the ABCs of HIV prevention. The
``A'' is for abstinence in young people, the ``B'' is for being
faithful in a mutually monogamous relationship, and the ``C'' is for
condom use in high risk populations with the knowledge that condoms are
highly effective in preventing HIV infection and gonorrhea in men, but
not as effective with all sexually transmitted diseases. I have
traveled to Uganda, and I have seen that ABC is working. Uganda is the
only country in Africa with an increasing rate of life expectancy. The
ABC prevention concept is something that we should seriously examine in
our own country.
All this is possible because of the hope of care and treatment. We
at HHS, in partnership with USAID and other organizations, are making
good on this promise. We are providing the essential training,
technical assistance and financial support to governments and
scientific institutions around the globe to help them help their
people. None of this would be possible without the continued support of
members of this Committee and your colleagues in the House and Senate.
Thus far, I have focused on HIV and AIDS in this testimony. Let me
now make a few comments regarding HHS's contributions to the global
control of tuberculosis and malaria. HHS's approaches to both TB and
malaria are similar to that of HIV/AIDS, but are more limited in terms
of scope and resources.
Both NIH and CDC work to address TB. TB is a global emergency and a
leading infectious killer of young adults worldwide. Approximately one-
third of the world's population is infected with the bacteria that
causes TB and 80 percent of active TB cases originate in 22 high-burden
countries. As I noted earlier, TB accounts for one-third of deaths
among persons with AIDS. Basic research on TB, including research on a
TB vaccine, is conducted at NIH. CDC supports applied research,
including operational research to improve programs and clinical
research to evaluate new drugs and diagnostics, and program
implementation.
In addition to addressing HIV and TB coinfection through the Global
AIDS Program, CDC works closely with USAID, international
organizations, and 16 countries around the globe to control TB.
International partners include the WHO and the International Union
Against TB and Lung Diseases (IUATLD). Collaborative efforts include
the Stop TB Partnership, technical support to USAID, and technical
assistance to specific countries. Technical assistance is focused on
countries which contribute most to U.S. cases, are high burden
countries, have high rates of multi-drug resistant TB (MDR-TB), are of
strategic importance (e.g. countries participating in the HHS Global
AIDS Program), or provide opportunities to improve diagnosis and
treatment of TB, MDR-TB, and HIV-associated TB.
Spearheaded by the WHO and its international partners, including
HHS, a proven effective national case management strategy has been
increasingly applied in developing nations. This strategy is termed
DOTS--Directly Observed Therapy, Short-Course--which emphasizes
consistent drug supply, microscopic based diagnosis, and direct
observation of each dose of life saving medication. The World Bank has
ranked DOTS as one of the most cost-effective of all health
interventions. CDC works with WHO and other partners to expand the
current DOTS strategy so that people with TB have access to effective
diagnosis and treatment, and to adapt this strategy to meet the
challenges of HIV and multi-drug resistance.
CDC and NIH are also actively involved in research on global
malaria prevention and control. NIH is engaged in research both
domestically and globally with a focus on malaria vaccine development
and optimal use of the information on newly characterized malaria
genome and the mosquito vector genome. CDC continues to work on U.S.
domestic prevention and monitoring and on global collaborations with
Ministries of Health, U.S. universities and schools of public health,
and non-governmental and faith-based organizations in the prevention
and control of malaria in malaria-endemic settings--mostly in sub-
Saharan Africa. In fact, much of the HHS global work on malaria is in
the same setting where HIV prevention work is underway.
The HHS effort in malaria is widely collaborative with the
Department of State, USAID and the Department of Defense. The U.S.
leadership in the Global Fund to Fight AIDS, TB, and Malaria has been
especially well-received in the malaria community.
Currently available control strategies for malaria have proven to
be highly effective in saving lives. Effective prevention exists, as
evidenced by the 20 percent reduction in child mortality with the use
of insecticide treated bed nets in Africa. Effective antimalarial
treatment exists that cures infection and disease. Use of insecticide
treated bed nets and preventive treatment can dramatically alter the
impact of malaria in pregnant women and their newborns, improving
newborn birth weight and reducing anemia in the mother and the newborn,
and saving lives.
Finally, as a reason to care about malaria in the context of HIV
and AIDS prevention and control, recent studies have shown that malaria
and HIV interact broadly. Malaria causes anemia and the needed blood
transfusions can be a source of HIV transmission. HIV-infected pregnant
women disproportionately contract the disease and exhibit more severe
complications, conferring a greater risk to the developing fetus and
the newborn. Most recently, studies suggest that malaria is more severe
in HIV-infected adults and that malaria may stimulate HIV viral
replication, with potentially greater increased risk for HIV
transmission. The widespread co-existence of malaria and HIV in Africa
likely means that each is making the other worse and that addressing
both is a good policy.
I thank you again, and welcome any questions you have for me.
Mr. Bilirakis. Thank you very much, Mr. Secretary. I'm
concerned. I've always been concerned when it comes to matters
such as this. Research, for instance, medical research, for
instance, coordination, lack of duplication of effort and I
understand and I've been told and I guess I'm pretty well
convinced that there has to be some duplication of effort when
it comes to medical research, although I wonder if it has to be
quite as much as now takes place.
So let me ask you then about coordination. For instance,
the services provided by the Department of HHS, services
provided by the Department of State, namely, I guess, US AID.
We have the Centers for Disease Control. They will provide some
sort of a role as far as this is concerned. Will they not?
Mr. Allen. That's correct.
Mr. Bilirakis. They will. So let me ask you then, how do
you look at it from the standpoint of coordination? I mean
resources, sure, we are the wealthiest Nation in the history of
the world, but as we're finding out, particularly this week,
resources are limited for whatever reason, one reason or
another.
So it's best and as I said in my opening statement and I'm
sure you agree that we be as efficient as we possibly can be.
Can you respond to that in terms of coordination and making
sure that the right hand knows what the left hand is going and
there won't be any unneeded duplication, etcetera?
Mr. Allen. Yes, Mr. Chairman. It's an excellent question in
this regard, and it really focuses on how do we make the most
use of U.S. resources in terms of addressing HIV/AIDS,
tuberculosis and malaria. And frankly, any other issues that
we're trying to address internationally.
One of the exciting things that has happened over the last
year is with the President's announcement of the Mother to
Child Transmission Prevention Program. Through that program, we
developed a model that we believe has worked very effectively
and we believe this is also a good model to look at in terms of
the President's emergency program for AIDS relief in Africa and
the Caribbean.
That model actually consists of having USAID, HHS, the
State Department, Office of Management and Budget working
together and reviewing the 14 countries in which we will be
having the Prevention of Mother to Child Transmission Program
initiative effective where they're reviewing the grants
collectively, making decisions collectively and have found a
model that actually works on the ground and that is what we'll
be promoting.
With that program, within 4 months of setting up the
President's Mother to Child Transmission Prevention Program, we
were able to get out four countries fast tracked under that
program, Haiti, Uganda, two other countries--let me see,
Botswana and I want to forget the fourth one. In the four
countries that we've worked in that we fast tracked, we have
been able to get out funds recently where they submitted plans
and now we're monitoring those plans.
Under this program, we also have set up four, what would be
work streams that are looking not only at the medical piece of
the plan, but we're looking at the governance piece of the
plan, looking at what accountability measures are put in and
we'll be following that through completion of the plan. And
that is a model that we think not only is effective in terms of
coordinating U.S. Government activities, but it also forces
coordination of activities in the recipient country, that they
will be coordinating their activities across the board to
address and get the maximum benefit of the resources that we
will be providing and that they will be also utilizing in their
countries.
In those countries what will happen is that we will be
setting up a series of clinics that we'll be working through
that are multi-stage--first of all, we'll start with a central
approach, but we will work central medical centers that will be
the hub of activity. These are existing hospitals. From there,
we'll work through primary satellites that reach beyond those
primary centers to begin to have intake of mothers to be
tested, screened and then treated. And then we have secondary
satellite sites as well. And then ultimately, we'll have rural
and mobile units as well working. That is an effective way to
build a program on the ground and then have it expand out into
farther reaches in those countries.
We believe the coordination is key and we think that we
have hit on something that actually can work and be very
effective in marshalling the resources that the Congress has
entrusted to us to marshall, not just HHS, but across the
government as well.
Mr. Bilirakis. Will that type of an effort be enhanced by
the additional dollars that the President has already relayed
to us?
Mr. Allen. We believe that that is exactly a great model to
pattern this after and the reason for that, we think that as we
look at these 14 countries and the reason why we've chosen to
target those 14 countries with the President's emergency
program for relief of AIDS, we believe that we've already got a
model that's working. We already know that they carry about 50
percent of the HIV cases in the world that we'll be trying to
address, and we think that this is a model that can work very
effectively.
The other two countries, I'm sorry I mentioned--the four
countries that we fast tracked already are Haiti, Kenya, South
Africa and Uganda. And then we have the 10 others will come
along.
Mr. Bilirakis. Mr. Secretary, I've gone over my time, but
with the indulgence of the few members who are here, just very
quickly, you emphasized that we not in a sense, you didn't put
it this way, but shoved down the throats of these countries our
way to do this. You emphasize, I think, that they should come
up with a system which is compatible, if you will, with their
demographics, with their population.
Uganda's ABC program, is that something that they
initiated?
Mr. Allen. Yes, it is. In fact, what's amazing about the
Uganda program is that it relied upon at a time when they were
not getting a lot of assistance from donor nations and they
developed a program that worked very effectively. They turned
back to their culture and they looked at what their culture had
and one of the things that they honored in their culture was
for young women to be virgins until they were married, until
they were at the age of marriage.
Mr. Bilirakis. Right, you explained that in your written
statement.
Mr. Allen. That's right and additionally what was
interesting, the B part of it, the being faithful was a zero
grazing policy, something that resonated in their culture. And
it is our belief that that program of the A and the B and then
condom usage in high risk populations was very effective in
driving the disease down.
And I've seen that replicated in other countries where if
you look at the cultures of these countries there are certain
moral values, certain traditions in which those countries, if
they can tape into, have a tremendous potential to address the
AIDS crisis in those countries.
I'll give you one specific example that doesn't focus on
the disease, but actually focuses on what happens when the
people are dying from the disease, the orphans issue. Uganda,
once again, has turned back to its culture to look at how it
will care for orphans. The First Lady of Uganda, Janet Museveni
is very adamant in not talking about having orphans or having
orphanages. She believes that it is their culture that they
would care for individuals who lost one or both parents within
the community and that is something in that culture that she
spends a lot of time addressing, of how do we care for our
young in the cultural context. I think we need to be very aware
of the culture that exists around the world that are different
from our own and be willing to work with them to find ways to
use cultural messages to promote cultural values that protect
health and welfare.
Mr. Bilirakis. And I think it used to be a part, a major
part of our culture a few years ago, sort of changed hasn't it?
Mr. Allen. Indeed.
Mr. Bilirakis. I will yield to Mr. Brown.
Mr. Brown. Thank you, Secretary Allen. Thank you again for
joining us.
You talk in your testimony about CDC's Global AIDS Program,
how CDC has great expertise in dealing with international TB,
largely through US AID funding. The President's plan, the $10
billion, $15 billion overall, suggested $200 million per year
and the Global Fund did not, to my knowledge, mention CDC.
Are you expecting a significant number of those dollars to
go into--to go either through US AID to CDC or directly to CDC
for TB and malaria--TB and HIV?
Mr. Allen. If I'm understanding your question, Congressman
Brown, is that this refers to the Global Fund dollars?
Mr. Brown. First to the other dollars.
Mr. Allen. Okay, to the dollars, the bilateral dollars, we
will be utilizing some of the funds that currently exist that
CDC receives for their tuberculosis treatment. Within the
President's initiative, the way we have set it up as we're
treating, for example, in our Mother to Child Transmission
Program which we think will be the model for the President's
emergency initiative, we treat mothers who we're bringing in to
test for HIV, we find them with tuberculosis, we will treat
them through that program. And so there will be dollars that
will be utilized within the President's proposal, not only for
HIV infection, but also for tuberculosis and malaria, whatever
conditions they may have, we will try to treat those.
Mr. Brown. From my involvement, especially in TB, but all
three of these infectious diseases for the last several years
on this committee and on the International Relations Committee,
I've just seen a much better--of a much more efficient,
effective use of dollars on infectious disease with CDC than I
have with US AID and I would like that to be reflected in the
record and taken back to the Secretary. But I want to shift for
a moment to the Global Fund. You said Secretary Thompson and
I'm thrilled, and as I've told him personally after another
hearing on another subject a couple of weeks ago that he is the
chair of the Global Fund. And you said that he will do all he
can to make sure that the Global Fund will well funded. You
spoke also in your oral testimony about the leverage that the
Global Fund, that our dollars in the Global Fund can cause. You
did not say this, but implicit in your statement, I believe, is
that you can't do the same kind of leveraging and bilateral
money in the US AID or under the State Department the way we
can through the Global Fund.
The Global Fund needs $6 billion they say over the next 2
years. The President has suggested only $200 million each year
for the next 5 so that's $1 billion total out of the $10
billion new dollars. Again, the Global Fund says in the next 2
years it needs $6 billion. Our Secretary of HHS in our country
is the chairman of this committee. Shouldn't we authorize and
appropriate significantly more than that?
Mr. Allen. I think that we have appropriate sufficient
funds currently for the Global Fund and we can look at that.
One of the issues that we have to be very careful about is in
terms of the balance. Right now, we're funding for the 2003
period, 35 percent of the fund. We have----
Mr. Brown. Total dollars? Speak dollars and percentages, if
you would.
Mr. Allen. That's correct. In terms of dollars, our pledge
is about $1.6 billion over the course of the next 5 years is
the total pledge that we have going toward the Global Fund as
we're proposing.
Of that amount, it is imperative and this is the
secretary's desire as chairman of the board is that we need to
increase the support that the Global Fund has from other
nations.
Let me give you an example of what I'm looking at here.
When I look at countries that have contributed to the Global
Fund, Spain has a 2-year commitment; Sweden has a 3-year
commitment; looks like $69 million for Sweden. The U.S. by far
has made a longer term commitment and a much higher commitment
to the Global Fund. We believe it is important that there's an
important role the Global Fund plays and we should be
supportive of that, but we also believe that we need to be very
careful not to have the U.S. fund the work of the Global Fund.
Just as the President envisioned and Secretary General Kofi
Annan envisioned when they had the Rose Garden announcement in
2001, this was supposed to be a public/private partnership;
public being multi-government and private being bringing
industry and NGO's. And currently that is not the way the
Global Fund is----
Mr. Brown. If I could interrupt. We are not known, if you
look at statistics, as doing well more than our part in terms
of international global poverty and infectious disease.
We rank near the bottom in the percentage of our GDP that
goes to any kind of international poverty issues. And for us to
sort of back off and say well, we've done more than anybody
else. We've done enough. Perhaps on some limited scale we have
and I'm very appreciative for what our government has done,
what the President is suggesting. But if the Global Fund is
going to work and we're always willing to step up militarily as
the last night's events and today's events show where we ought
to be willing to step up and lead. And that just doesn't mean
more than any other country. It means step up and lead and
leverage the money the way that we can do.
You talk about 14 countries and I appreciate those are
the--you said 50 percent of those 14 countries, 50 percent of
the AIDS in the world are in those 14 countries. I'm sure
that's true. But TB it's not even close to that. And malaria
it's not even close to that. And AIDS in China and Russia, it's
not even going to be close to that.
Can I have an extra 2 minutes, Mr. Chairman?
Mr. Bilirakis. Without objection.
Mr. Brown. Thank you.
Mr. Bilirakis. You've already used one of those.
Mr. Brown. I said additional. But it's clear that we need
to look larger than those 14. When China and India, when HIV
and TB intersect, as Donna Berry's boss says it's the perfect
storm and we're going to see numbers rivalling the Great
Plague. And if we step up only sort of put our foot in the
water, that's really all we've done and it may sound like a lot
of dollars, but we're really not doing as much as we should do.
One more point and the model of one size fits all, the
Uganda program sounds terrific. I'm really glad we're doing
that, that they're doing that and if we can help, but what
works in Uganda, what works in a Christian nation may not--a
Christian Brazil may not work in a Muslim Bangladesh and what
works in Uganda is great, but the CDC, the US AID shouldn't be
citing this is the model and pass it around country to country.
The Global Fund should make those bilateral decisions, should
make those decisions with input from an NGO in Bangladesh or a
government--a health ministry in Mexico and fund that way,
rather than the U.S. deciding bilaterally this is the best way
to do it. Those countries can decide it best.
I frankly have more confidence in the Global Fund working
and fitting into that country and doing the local control than
I do US AID which has not always done that so very well.
Mr. Bilirakis. A very brief response to that.
Mr. Allen. Certainly, I would comment on two things. We're
not here to advocate one or the other. We believe both are
important. The bilateral host is targeted, it's focused and it
is able to get out very quickly. We've gotten grants out in 4
months. Global Fund has a role to play in that it can reach
much more broadly to address many of the issues that you've
raised. We think that both are important, but we need to be
very careful on how we balance the resources that go in to
ensure that the Global Fund particularly, has multilateral
participation.
Mr. Bilirakis. There's enough flexibility in the use of
this $10 billion and in the workings of the Global Fund so that
if it is determined, after all, the chairman is Secretary
Thompson, if it is determined that additional resources above
and beyond those that are committed might be very helpful, you
know, from maybe a short term standpoint that can take place?
Mr. Allen. We would certainly appreciate that flexibility
with the $15 billion.
Mr. Bilirakis. Mr. Pitts.
Mr. Pitts. Thank you, Mr. Chairman. Thank you for convening
this important hearing and I want to submit my opening
statement for the record.
Mr. Secretary, some are arguing that we should use U.S.
taxpayer funds and entrust those funds to the Global AIDS Fund
rather than a U.S. controlled bilateral program efforts to
address AIDS issues globally.
Some people are concerned that the Global AIDS Fund is
untested and unproven, unaccountable to the U.S. In fact, the
Global AIDS Fund has recently announced that it will give some
$20 million to what the administration has labeled as the axis
of evil, $16 million to Iran and another $5 million to North
Korea. What are your thoughts on the support for the Global
AIDS Fund versus bilateral efforts?
Mr. Allen. I want to go back to my earlier comment in terms
of the difference between bilateral efforts and multilateral
efforts, i.e, the Global Fund in this case. They serve two very
important purposes, but in some ways very unique purposes that
are complementary We believe in bilateral efforts as in the
U.S. Government because it allows us to work with existing
partnerships that we have. In the case of HIV/AIDS,
tuberculosis and malaria, the bilateral relationships that we
have through the Global AIDS program, we already have people on
the ground in many of the 14 countries that we're talking
about, programs that are up and working and therefore we were
able to very quickly target prevention of mother to child
transmission with 4 months after we started the program. We've
got money going out the door between $19 and $29 million to the
first four countries and within a couple of weeks we'll get it
to the other 10. And so bilateral relationships are very
important because we're able to target our activities and focus
on those countries that again, in this case, those 14 account
for about 50 percent of the AIDS cases worldwide.
On the other hand, the Global Fund is also important. It's
important because it is able to do exactly what you're talking
about in terms of looking at the humanitarian issues that
people are confronting. And while your comments in terms of
specific countries and the axis of evil, we do work with
countries that we either do not recognize or we do not have
formal relations with. Why? Because we believe that when people
are suffering we don't punish people because of their
governments. Case in point of what we're doing, absolutely
right now today. We are not battling the people of Iraq. We're
not fighting them. We're seeking to have a leadership change in
that country because of the impact that that leadership has had
not only on its own people, but on the world and so I would be
very careful not to seek to so narrowly constrict the U.S.
participation or resources going to multilateral organizations
on a strictly black and white test, whether you're for us or
whether you're against us.
What you need to tie it to is very specific strategic goals
that serve not only the U.S. interest, but also the world
interest in terms of humanitarian assistance.
Mr. Pitts. So what assurance do you have from the Global
Fund that they make sure that the international sponsors of
terrorism, like in Iran or in North Korea, that the money goes
to the people who need it?
Mr. Allen. One of the things we have done is specifically
and we have some examples of this, is where Secretary Thompson,
for example, has met over the last week with Secretary General
Annan. He's met with Dr. Piot, the head of U.N. AIDS, other
organizations in terms of the Global Fund to talk about these
very issues. And what we have done is the Global Fund in many
of these countries, for example, in North Korea, they're
targeted specifically not to be funds that go to the
government, that the government controls, but rather to work
closely with nongovernmental organizations, with faith-based
organizations and so that we know that that money is not going
to serve the governments of those countries, but rather are
going specifically to serve the people of those countries in
terms of addressing the disease burden that they're carrying.
Mr. Pitts. Another issue. Microbicide research is often
mentioned as necessary to help prevent the spread of AIDS. In
fact, at least three separate agencies are conducting this type
of research, CDC and USAID and NIH. What protocols currently
exist between these three agencies to guarantee that there will
not be duplication of effort and then if I can ask you part b,
we're spending over $100 million annually to develop these safe
sex programs. Can you comment on the role that microbicides may
play in global AIDS programs?
Mr. Allen. Certainly.
Mr. Bilirakis. The gentleman's time has expired, but
certainly I will allow you to respond.
Mr. Allen. Thank you, Mr. Chairman. As I understand your
question, the first question, the Centers for Disease Control
and National Institutes of Health are very actively involved in
microbicides research. Because those two agencies come under
the Department of Health and Human Services, we are working
very aggressively within the Department to ensure complementary
research, not overlapping research or duplicative research.
We're also coordinating our efforts and activities with the
Department of Defense and their research efforts. In fact, on
my most recent trip to Ethiopia, I had the privilege of
visiting with and was briefed by the Department of Defense
about their activities in country. And so we are trying to
coordinate our activities in terms of HIV/AIDS, tuberculosis,
malaria, the health activities that we're working in countries,
both here in the United States, but we're actually trying to
coordinate those activities in the field so that we're working
together.
A good model of that was the most recent vaccine trials
that are taking place in Thailand that are being conducted by
the military. DOD is overseeing it, but they're doing it with
the cooperation and assistance of HHS through the National
Institutes of Health. So those are some models that are already
existing and we're working to coordinate those activities and
working much more closely together than I may have been in the
past.
Mr. Bilirakis. Thank you, Mr. Secretary. Ms. Capps to
inquire.
Ms. Capps. Mr. Allen, you say in your testimony that
condoms are and I quote, ``highly effective in preventing HIV
infections and gonorrhea in men, but not as effective with all
sexually transmitted diseases.''
In the many situations where abstinence is really not a
real life option, are you aware of other contraceptive methods
that are more effective than condoms in preventing these other
sexually transmitted diseases?
Mr. Allen. In terms, as I understand your question, if
there are more effective methods than condom uses in preventing
the transmission of diseases, one of the areas that we're
exploring is the area of microbicides. That certainly is an
area in some circumstances have been--we have trials that are
being conducted, a new compound that is being evaluated, a
microbicide to be utilized, to be evaluated to see its
effectiveness.
In terms of condom usage and its effectiveness, the
National Institutes of Health and Centers for Disease Control
in 2001, I believe it was, submitted a report that talked about
the effectiveness of condom usage and it said exactly that,
that they were highly effective in preventing transmission of
HIV and gonorrhea in men and less effective in many other
areas. And so we do need to focus on what can work, what is
working and of the means for preventing contraception, the
condoms are not the most effective for preventing
contraception.
Ms. Capps. So you're saying that the microbicides are being
evaluated, so they're still in the testing phase? They're not
readily available and would there be a cost barrier or some
kind of access that would be something to challenge as well?
Mr. Allen. Well, one of the areas that we're certainly
looking at----
Ms. Capps. You answered. I do want to get to another point.
Mr. Allen. Certainly. One of the areas that we're certainly
looking at are the whole range of what would be--that are being
researched of microbicides and other activities that can serve
in this area as effective tools. I don't have the answer for
you on what they all are, but I can provide that for you.
Ms. Capps. A yes or no answer. Are these now available for
the AIDS community?
Mr. Allen. Some yes.
Ms. Capps. Some are available now?
Mr. Allen. That's correct.
Ms. Capps. And being distributed?
Mr. Allen. Yes, they are.
Ms. Capps. Okay, good. I'm going to move on because there
is another topic I'd like you to speak about, but I hope that
you could respond to Secretary Powell's comment that will quote
with just a yes or a no. He was quoted as saying that the
``whole international community must come together and speak
candidly about'' and then what he was talking about sex and
AIDS. And forget about conservative ideas. He clearly wants to
put aside ideology and I'm wondering if you agree?
Mr. Allen. First of all, I cannot answer that with a yes or
no answer. I think it's important to put it into the context in
which Secretary Powell made that comment.
It is important and we believe that messages are important
for specific populations. For young people, we think a
consistent message of abstinence until marriage is the
healthiest and safest message and so in that regard, we believe
messages for target populations are appropriate.
For adult populations, fidelity is an appropriate message.
Ms. Capps. Which is part of that ABC that you were talking
about with Uganda.
Mr. Allen. That's correct.
Ms. Capps. I'd like to move on and I'm very mindful that
I'm going to get gaveled down in a minute. The administration's
track record on supporting comprehensive efforts really is not
very good. There have been so many efforts to undermine
confidence in condoms. At the 2002 U.N. Special Summit on
Children, the administration tried to skuttle the global
declaration because it encourages comprehensive sex education.
2002, in December, the administration tried to delete a
reference to consistent condom use and I quote from another
report of another U.N. sponsored conference. ``This does not
fill me with confidence that a comprehensive approach is really
a goal.'' I'm wondering how you can distinguish yourself and
separate yourself from these past actions, as you're thinking
about the epidemic on our hands?
Mr. Allen. I think that it's important, if I understand
what your comments are reflecting on, for example, the Youth
Summit. I think the policy and the healthiest policy for young
people is abstinence. That is the 100 percent safest, most
effective way of preventing not only contraction of HIV/AIDS
and other sexually transmitted diseases, but in many cases the
most effective way for preventing----
Ms. Capps. We have tied abstinence only, sex education, to
our welfare reform bill, despite my protestations. Would you go
that far with your efforts overseas?
Mr. Allen. Again, who am I to question the acts of
Congress. That's the legislation.
Ms. Capps. I think you could have an opinion on this.
Mr. Allen. I do believe in my capacity as the Deputy
Secretary, I do speak in terms of what the Department has
proposed and what we believe is that we need to have very
appropriate, age appropriate and targeted messages. And for
young people, that message is a very clear on, that we're
seeing kids, very young ages, contracting HIV/AIDS, contracting
sexually transmitted diseases where they're not protected by
the use of contraception.
We also know that with young people that they're risk
takers and therefore we need to strategize and have appropriate
messages that protect them and the message that the
administration has promoted, whether that is domestically or
internationally that we're finding is a message that is
consistent that protects 100 percent of the time.
Mr. Bilirakis. Time.
Ms. Capps. I just want to follow up----
Mr. Bilirakis. Listen, we have to finish up here some time.
We can't continue.
Ms. Capps. I just want a yes or no----
Mr. Bilirakis. You want a yes or no to your question?
Ms. Capps. Yes, to a question. Will AIDS intervention
include--as comprehensive, include condom distribution?
Mr. Allen. ABC includes condom and distribution.
Ms. Capps. And that's part of your----
Mr. Allen. That certainly is.
Mr. Bilirakis. But that's decided upon by the particular
locale, is that right?
Mr. Allen. We would be very consistent, again. We believe
it is not the place of the United States to impose upon
countries the programs that they should have, but we believe
that a comprehensive approach means having age appropriate and
situation appropriate messages. And ABC is a very consistent
message that says condom usage in high risk populations is an
appropriate means----
Mr. Bilirakis. But you have also indicated that the United
States, in spite of the fact that we have a leading role here,
would not shove that done--ABC or any other program, down the
throats of any----
Mr. Allen. I do not believe that is appropriate for us to--
--
Mr. Bilirakis. He said that earlier before you came in.
Mr. Brown. Would the gentleman yield? I'm confused about
one answer.
Mr. Bilirakis. Quick answer and a quick response so we can
continue here.
Mr. Brown. Well, why you wouldn't tel la country to do
that, would you refuse to fund a country that doesn't, that
doesn't follow the model that you're suggesting?
Mr. Allen. Again, in terms of----
Ms. Capps. For any group.
Mr. Brown. Would you refuse to fund a program that doesn't
go along the lines of ABC?
Mr. Allen. I think it's important that programs we would
support, it's not a yes or no answer, frankly, because again,
each country is going to be very different in how they approach
it.
We currently fund programs that do not follow----
Mr. Bilirakis. You said countries approach it differently.
Would you still fund that country?
Mr. Allen. If they had a sound model that can support the
prevention of the transmission of the disease, we would work
with those countries to try to find----
Mr. Bilirakis. It may take more of a discussion than what
we have here.
Mr. Allen. I'd be glad to engage in that.
Mr. Bilirakis. Mr. Ferguson.
Mr. Ferguson. Thank you, Mr. Chairman. I appreciate your
holding this hearing and certainly appreciate the work of the
subcommittee for our continuing fight against the global AIDS
situation.
I know the chairman is aware, I want to make sure I call to
my colleagues' attention as well, that while we're united in
this global fight against AIDS to help needy people throughout
the globe, we have to work together to do the same for those
who are in need here at home. For too many Americans, these
treatments are out of reach without our help.
We have a very important program here at home called the
AIDS Drug Assistance Program and I would encourage my
colleagues to take a close look at this program because in too
many of our home states these programs are consistently
underfunded and they can't meet the needs of those who are
struggling with HIV and AIDS and who need help in getting
access to their medicine.
Secretary Allen, thank you very much for being here today.
I appreciate your testimony and under sometimes trying
circumstances.
In your testimony, you talk about--I have a long question
for you.
Mr. Allen. Okay.
Mr. Ferguson. So bear with me. In your testimony, you talk
about building and sustaining a research capacity in developing
countries including invaluable infrastructure building. You
discussed building onsites and programs which are already
established which is a strategy that's extremely important to
consider as we think about ways of addressing the AIDS
situation.
I'm also intrigued though by approaches that involve
private sector entities, both for profit and nonprofit, private
sector entities in supporting various countries AIDS programs.
There are many private sector entities that have forged
valuable partnerships to train medical personnel and build
critical infrastructure, not to mention generously donate
important resources and medicines. One such program that I want
to mention is the African Comprehensive HIV/AIDS Partnerships
or the ACHAP program. It's a public/private partnership between
Merck and the government of Botswana and the Gates Foundation,
which I'm sure you're familiar with.
As you know, this is a program which is working with the
government to implement a comprehensive program for HIV
prevention, treatment and monitoring that involves
strengthening the country's health care infrastructure.
It's not enough just to provide medicines. Obviously, we
have to have ways and means of getting these medicines to the
people who need them and that's why the infrastructure, as you
know, is so important.
There are a lot of other initiatives including the
accelerated access initiative and other partnership between
five U.N. organizations and the private sector, specifically
the research-based pharmaceutical industry to create--to
increase access to HIV and AIDS care and treatment in
developing nations.
My question, I just wanted to kind of get a little bit of
feedback from you and perhaps a little bit more of a detail of
your comments and thoughts on some of these partnership
programs and also your thoughts on possibly expanding these
public and private partnerships in the President's proposal to
try and build on some of the progress that we've already made.
Mr. Allen. Certainly. The President has articulated and the
Secretary has also articulated the importance of the private
sector, both the NGO community and the corporate community in
battling not only HIV, but tuberculosis, malaria and other
diseases.
That is why we're focusing so much on our bilateral
programs. The U.S. has a history of working very closely with
the private sector, the NGO community and faith-based
organizations who in many of these countries are the ones who
are providing the prevention, providing the treatment and the
care. They're the ones who are doing the counseling and
testing. And we believe that that is a model that has worked
very well, not only in this country, but through our programs
internationally as well.
And for that reason, Secretary Thompson is now the chair of
the Global Fund, as wanting to see the Global Fund move more to
partnerships with both the private sector, the NGO community
and the faith-based community to get them involved in those
countries. And so that is a very critical element of what we
think is going to be the key to success in combatting HIV,
tuberculosis and malaria as both bilaterally and multilaterally
through the Global Fund. So that is a linchpin to what we're
talking about.
On top of that, we also recognize the need for models and
the model that we have hit upon that we believe is working
effectively and can continue to work effectively is the network
model that I described earlier which is building upon the
infrastructure that exists. It starts in the urban area and
builds out from there. As you build capacity, you're able to
leave behind the infrastructure a trained professional health
core there to provide the services that we will not always be
there to provide. And so that's a very key element.
Mr. Ferguson. And that, in fact, is in addition to the
lives that are saved, obviously, that infrastructure which is
left in place for years beyond is a legacy which we should be
so proud of.
Mr. Allen. Absolutely. I have traveled throughout Africa
over the last 2 years to many countries and the two things that
I often hear from those that I visit with are they're so
appreciative for the technical assistance that we provide that
the U.S. brings through it's multitude of agencies and
departments that are working there, but also the fact that we
leave behind something that is tangible, equipment. We leave
behind trained professionals and we leave behind methodologies,
protocols that they can buildupon to serve their own people and
that's key in terms of what we do.
Mr. Ferguson. Mr. Chairman, I know my time is up. I don't
have another question. I just want to close by saying I for one
am tremendously proud of these research-based companies which
not only are donating millions and millions of dollars worth of
these medicines which they have invested and worked so hard to
produce, but are also cooperating in these public/private and
nonprofit partnerships with countries like Botswana where my
uncle served in the Peace Corps, to try and help these
populations and to set up these infrastructures which are going
to be there far beyond the life of these actual----
Mr. Bilirakis. The chair thanks the gentleman.
Mr. Ferguson. Chairman Bilirakis, I yield back.
Mr. Bilirakis. Mr. Ferguson, we're all in good moods the
week of St. Patrick's Day.
Mr. Green.
Mr. Green. Thank you, Mr. Chairman and Secretary Allen and
welcome to our Health Subcommittee.
Mr. Allen. Thank you.
Mr. Green. I want to shift the focus just a little bit to
one of the concerns some of us have is tuberculosis and these
days it's an increased prevalence and a multi-drug resistant
tuberculosis which is not easily treated by our traditional
means.
What kind of research conducted at NIH to develop new
treatments for this drug-resistant, multi-drug resistant
tuberculosis and at CDC to prevent this dangerous chain of
tuberculosis? And again, some of us on the committee, both our
Ranking Member, Mr. Brown and I have a District in Houston and
if there's a problem in Latin America, we're going to have it
in Houston or Miami or the border regions, along the United
States and I appreciate the effort.
Mr. Allen. Certainly. Mr. Green, one of the things that
we're doing through not only the NIH, as you identified, but
the Centers for Disease Control, is that we are working with
the World Health Organization, the International Union against
TB and Lung Disease, as well as USAID to address tuberculosis
worldwide.
The United States, we prioritize our activities based upon
a number of things. First of all, those countries that
contributed most to the U.S. cases, that's a strategic issue
that we're addressing. Second, those countries that have high
burdens of tuberculosis and then third, those that have high
rates of multi-drug resistance, TB and then additionally, we
are looking at strategically important countries, those
countries in which we have relationships, the GAP countries,
the 14 countries that I mentioned in Africa and the Caribbean
that we're already working in and those are the countries that
we're focusing our activities on.
It includes not only research, but it also includes
expansion of what are directly observed treatment programs that
short course treatment programs and we even have a U.S.-Mexico
border initiative that is focusing on tuberculosis. So across
the government, we are very keenly focused on tuberculosis
prevention and also in terms of the research that addresses the
multi-drug resistant strains that we're finding. And that
research is carried on both domestically and internationally
that we're working on and I'd be glad to supplement my comments
for the record if that would help you to give you some more
details on what we're doing.
Mr. Green. I'd appreciate it and I think other members of
the committee--should we provide the Secretary expanded funding
for the CDC in their international tuberculosis effort along
the lines of the Global AIDS program at CDC?
Mr. Allen. The way that we have--we have about $2 million,
I believe it is, in CDC for Fiscal 2002 that we were using in
terms of tuberculosis itself, just as separate and apart from
what we were doing internationally. I believe the funding that
we have through the program that we've set up, particularly,
for example, the Mother to Child Transmission Prevention
program that one of the things we will be addressing as we're
caring for those mothers with HIV/AIDS is we're treating them
for tuberculosis as well. So the money, when we've asked for
the international programs that we're talking about, that would
include tuberculosis. It doesn't simply include HIV/AIDS. It
goes beyond that to include tuberculosis.
Mr. Green. I guess one of my concerns is the President's
AIDS announcement is very important and a historical step in
addressing AIDS in those 14 countries, but does not address
AIDS and tuberculosis in a comprehensive way. The President's
2004 budget actually cuts the bilateral tuberculosis and
malaria funding by some $80 million and greatly under funds the
Global Fund on AIDS and tuberculosis and malaria.
Is there a--can you give me a response to that? I know that
there's been some success, but I also want to make sure it's a
success across the board.
Mr. Allen. No, I don't find any cuts in terms of our
tuberculosis or malaria funding. For example, in fiscal year
2002, tuberculosis funding was at $73.6 million and in 2003 it
was $81.7 million and our 2004 request if $86.1 million, so
we're increasing our request for funding for tuberculosis.
In malaria, there's a similar trend; 2002, $95.7 million;
2003, $105.3 million and our 2004 request is $109.1 million,
and that's only within HHS, that's the National Institutes of
Health. That does not include what USAID has requested in these
areas as well and what they've received as well. So I'm not
sure where the idea that there's a cut coming from. That
doesn't support our budget chop.
Mr. Green. Thank you, Mr. Chairman.
Mr. Bilirakis. I thank the gentleman. Ms. DeGette to
inquire.
Ms. DeGette. Thank you, Mr. Chairman. Mr. Secretary, I was
very pleased when I heard the President talk about the new
emergency plan targeted at the 14 countries for AIDS and I
wanted, I've been wondering about some of the details of the
plan. Maybe you can help me with some of those.
I know that the President in his budget commits $10 billion
in new money over 5 years to go to these targeted countries and
I'm wondering how that money is going to be spent? I saw in
your written testimony, for example, that you're planning to
treat 2 million HIV-infected with anti-retrovirals and give
health care to 10 million additional HIV-infected individuals
and orphans.
I'm wondering what the thinking is behind giving
retrovirals to only 2 million folks and then I guess just
giving palliative care to 10 million additional folks. Why not
try to maybe negotiate with the pharmaceutical companies or
find some way to provide many more people with the option of
having the retrovirals so we could actually keep them alive
longer?
Mr. Allen. What we're focusing on is what the U.S. is doing
in terms of our bilateral relationships and our bilateral
programs. This is not to speak about the multilateral programs
that will be undertaken in these same countries or even the
private sector initiatives that will be undertaken. There's
been mention of some of the corporate citizens of the U.S. who
are already in Africa with programs that are underway.
The 2 million that we're talking about really focuses on
the mothers that we anticipate will be working with us in our
programs that will come into the clinics, be treated and then
we will follow them in their communities.
Ms. DeGette. And you're going to be giving them the drugs
though, right?
Mr. Allen. Correct.
Ms. DeGette. With the onset of AIDS?
Mr. Allen. Correct.
Ms. DeGette. How many of the rest of those millions of
people who have HIV are going to be able to get the drugs
through private multilateral efforts?
Mr. Allen. Through the private multilateral efforts, I
don't have a number. That is----
Ms. DeGette. You can see what I'm--and then will the rest
of the $10 billion be spent on programs like this ABC program
and other types of prevention programs? Is that the
administration's plan?
Mr. Allen. The idea is that we will focus on prevention,
treatment and care and research as well, in terms of what we're
looking at for the President's program. The program will break
out----
Ms. DeGette. I mean it just seems--my question, and you
know what I'm getting at.
Mr. Allen. Actually, I'm not quite sure.
Ms. DeGette. Let me try to be specific. We have--I don't
know how many million people in these 14 countries are infected
with HIV. Do you know that number? Someone is whispering to
you. Do you know that number?
Mr. Allen. I'm sorry, I missed your----
Ms. DeGette. How many millions of people in these 14
countries that the administration is targeting, the 12 Sub-
Saharan countries and the other two countries are infected with
HIV?
Mr. Allen. I can get you those numbers.
Ms. DeGette. Thank you.
Mr. Allen. Hold on for a second.
Ms. DeGette. Sure. Mr. Brown says about 25 million.
Mr. Allen. Yes, but you didn't want one specific community
totals then?
Ms. DeGette. No, right. I just want the total. I'm sorry.
So my question is you're putting $10 billion in new money over
10 years or I'm sorry, over 5 years.
Mr. Allen. Correct.
Ms. DeGette. In these countries. My question and what
you're going to do with U.S. dollars--with Federal dollars,
with government dollars is treat 2 million of these 25 million
people with anti-retrovirals, right?
Mr. Allen. That's correct.
Ms. DeGette. So my question to you is are these private
philanthropic and other efforts, the multilateral efforts you
spoke of how many of the remaining 23 million people are those
entities going to treat with the antiretroviral drugs?
Mr. Allen. I cannot give you a number as to what the
private sector or multilateral organizations will do. What I
can point to you to is what the Global Fund is trying to do.
Our efforts are very targeted, very focused on those 14
countries where we find half of the disease, have of those
living with the disease live in those countries. That's what
we're focusing and we're going to focus our activities
specifically.
Ms. DeGette. I think that's swell, but my question is about
the drugs.
Mr. Allen. Let me see if I can try to answer. If you will
be patient with me to try to get to your question. We are
working both the U.S. purchasing and providing anti-retroviral
treatment, but we also work multilaterally, whether it's
through the Global Fund or working with organizations that are
already in countries. We work in those countries to find ways
of providing antiretroviral treatments.
So there is multilateral activity taking place in which the
U.S. is participating----
Ms. DeGette. Right, I understand that. I do understand
that.
Let me just finish, if I may, Mr. Chairman.
My only question and concern is I think we need to try to
work as part of our plan which is multifaceted, I understand.
I think we need to try to work to get these drugs to as
many people as we can and any way we can which means----
Mr. Bilirakis. Mr. Allen, unless your response is brief, I
would suggest that you put it in writing, since that's one of
the things we're going to ask of you when we excuse you.
Mr. Allen. Certainly and I'd----
Ms. DeGette. Mr. Chairman, I think that's an excellent
idea.
Mr. Allen. I think that's perfectly----
Mr. Bilirakis. All right, great. We are finished up with
you, sir. Thank you so much. That's a bad way of putting it.
Mr. Allen. Thank you very much, Mr. Chairman.
Mr. Bilirakis. Thanks for your patience.
Mr. Allen. It's my privilege.
Mr. Bilirakis. And your understanding, Mr. Secretary. As
per usual, we will have questions. One has already been posed
by Ms. DeGette. Would you like to repose that in writing to
him?
Ms. DeGette. I think he understands.
Mr. Allen. I think I understand your question and I'd be
glad to----
Mr. Bilirakis. If you understand that, please respond to
the committee and of course, there will be other questions
submitted to you by the staff and what not and we would expect
that you would respond.
Mr. Allen. Certainly, Mr. Chairman, and thank you again and
it's a privilege to be before you on such an important issue.
Mr. Bilirakis. Thank you. Thank you so much. Let's see, the
second panel finally we come to it. Mr. Shepherd Smith,
President and Founder of the Institute for Youth Development;
Ms. Donna J. Barry, Partners in Health, Boston, Massachusetts;
Ms. Sophia Mukasa-Monico, Director of the AIDS Program for
Global Health Council here in Washington; and Dr. Edward C.
Green, Senior Research Scientist, Harvard Center for Population
and Development Studies.
Are we all here or are we not here?
Ladies and gentlemen, your written responses have already
been submitted to us, so we'll set the clock at 5 minutes and
we would hope that you would complement, if you will, those
responses more than anything else.
Mr. Smith, please proceed, sir.
STATEMENTS OF SHEPHERD SMITH, PRESIDENT AND FOUNDER, INSTITUTE
FOR YOUTH DEVELOPMENT; DONNA J. BARRY, PARTNERS IN HEALTH;
SOPHIA MUKASA MONICO, DIRECTOR, AIDS PROGRAM, GLOBAL HEALTH
COUNCIL; AND EDWARD C. GREEN, SENIOR RESEARCH SCIENTIST,
HARVARD CENTER FOR POPULATION AND DEVELOPMENT STUDIES
Mr. Smith. Thank you very much, Chairman Bilirakis. I'd
like to depart from my written comments right now and just be
responsive to some of the opening comments that were made.
First, I'd like to thank you for the many years you have
followed this issue, led on this issue and this committee has
contributed mightily to America's response and we're
appreciative.
I agree with Mr. Towns that this committee should be
involved in any legislation that is written or come sup in this
Congress because you really have the expertise.
Ms. Wilson, Mr. Brown and Mr. Green raised the important
issue of tuberculosis. Clearly, we have to have an emphasis on
that. One aspect of TB is in respect to how the medications are
administered by direct observed therapy. And one part of the
conversation about antiretroviral drugs for HIV that I think
was being omitted is the need for direct observed therapy in
these countries that we have targeted in the President's
initiative.
We do not want to put ourselves in a position where we
become responsible for helping facilitate the development of
drug resistant strains of HIV in parts of the world and so I
would caution in an program or legislation that that be a
consideration.
I wish Mr. Towns were here because he was very instrumental
in putting together the first hearing in 1995 on AIDS in the
African-American community and that helped move that issue and
funding in that direction which was much needed. With respect
to Ms. Capps' comments about the ABC of Uganda, I think that
it's important to remember that this isn't ABC in the context
that we think of comprehensive sex here in America. It's very
targeted. It's abstinence to kids. It's be faithful to those in
marriage or in monogamous relationships and it is comments to
very targeted communities such as the bars and the prostitutes
and so on. So it is ABC, but it's not all lumped together. It's
very segmented, having been there and looked at it very
carefully and I think you'll hear more from other panelists.
I just would like to hit on the summary points that I had.
We really need to address HIV internationally from a medical
public health perspective. We need to be more aggressive in
diagnosing the disease, meaning it should be a routine practice
in clinics that we establish to diagnosis HIV for people who
come in. We need to know who we can help and we need to help
people know if they're infected.
There's got to be greater coordination in whatever
legislation comes forward between the Department of Health and
Human Services, USAID and State Department and certainly CDC,
as Mr. Brown was concerned, should and will play an important
role, but it needs to be coordinated with respect to what other
people are doing.
Again, having been abroad, having seen for myself, we have
a great infrastructure on the ground. I would argue that the
United States should put the bulk of any resources into a U.S.
effort. The Global Fund, I am not convinced yet that it is the
best vehicle for this initiative. We are giving close to a
majority of the money that goes there, we're making substantial
contributions and I wouldn't suggest that we go beyond that.
The important selection of the coordinator who will be in
all likelihood at the State Department oversee these activities
is going to be a very important decision. The qualifications of
that individual are going to dictate a whole lot of how we
respond and we would urge the Congress to make sure that that
individual one is well qualified and two, has the ability and
authority to coordinate this massive effort.
Again, balancing prevention and treatment, we would argue
that we need to put a great deal of effort into solid
prevention messages because the more people we can have who are
uninfected, the less treatment we're going to have to give out
over time.
In respect to mother to infant transmission which was
mentioned, we're concerned that so much emphasis has been
placed on just the mother. In these countries, the father, the
husband is critically important to the family unit, often left
untreated. When that individual dies, the children are going to
be orphaned more quickly, the mother's health is going to
decline more quickly and she is left in many instances
virtually powerless without her husband, without that male
figure. So I think we need to work on saving the whole family
when we talk in the context of mother to child transmission.
Mr. Bilirakis. Please summarize, Mr. Smith.
Mr. Smith. Okay, I'm just going to end with the importance
in respect to Uganda. It's been mentioned a lot and I know it
will be mentioned again, but clearly they are an exception in
Africa to this epidemic and they've done it their way and it's
highly effective. Other countries have done it our way and they
are not effective. And I would say we need to pay more
attention to that model.
Thank you.
[The prepared statement of Shepherd Smith follows:]
Prepared Statement of Shepherd Smith, President, Institute for Youth
Development, Board Member, Children's AIDS Fund
Thank you, Chairman Tauzin, and all your committee members for
holding this hearing on such an incredibly important issue. The first
time we presented our views was in 1987 to your health subcommittee,
and subsequently gave testimony on several other occasions as president
of Americans for a Sound AIDS/HIV Policy in the 1990s regarding the
spread of the HIV epidemic in the United States and abroad, and the
need to address the epidemic from a medical/public health perspective.
This committee is well recognized as the primary House sponsor of AIDS-
related legislation throughout the history of the epidemic.
The attention the past chairmen of the full committee and the
subcommittee have paid to this issue is remarkable. Congressmen
Dingell, Waxman, Bliley, and now Congressman Bilirakis have all made
HIV/AIDS a top priority. You're following in that role, too: is very
heartening to those of us who care deeply about this issue. In past
legislation most HIV/AIDS programs and plans have focused domestically
while some of the resources that were allocated went to international
efforts. Now, because of the President's bold initiative, this
committee is looking more broadly at the implications of such a plan.
This issue has never been simple, and broadening our focus with
more intensity on a global level brings many challenges to bear. The
State Department and USAID have historically dealt with many
international issues, while the Department of Health and Human Services
has often played a significant role of offering technical assistance on
health related matters such as the successful campaign to eradicate
small pox and the present campaign to eradicate polio. While HIV/AIDS
is an issue that now impacts nearly all countries and has economic
implications, it is primarily a health issue which needs incredible
coordination between these three entities that have played historic
roles at the international level.
I was privileged to be part of the US Delegation to the United
Nations General Assembly Special Session on HIV/AIDS (UNGASS), and then
to travel with Secretary Thompson last year to Africa as part of his
delegation. We saw the consequences of this epidemic on that continent,
as well as began to shape answers that will benefit all countries.
Secretary Thompson's interest and leadership on HIV/AIDS has gone
mostly unheralded, but not unnoticed by those of us deeply involved in
this issue.
I was very impressed by the infrastructure established both by the
State Department and USAID, as well as the support staff provided by
HHS in many of the countries visited. Clearly the opportunity to help
country by country is well defined by the folks we already have on the
ground from the United States. It is my strong belief that we can help
significantly given clear leadership and direction from the top of most
parts of our government. Substantial and expanded United States
resources can probably be better utilized by a United States effort
than through the Global Fund to Fight AIDS, Tuberculosis, and Malaria
(Global AIDS Fund). This is not to say that there should not be a role
for the Global AIDS Fund, and indeed this Administration is giving
significant resources to it, more than any other country in the world.
However, when we're talking about mobilizing such a large effort in
such a short period of time, the United States alone is positioned to
do this much better than any international entity with all its
different perspectives and participants that come into play.
The need for a strong coordinator at the State Department makes a
lot of sense to us as well. It is the United States embassies and
consulates in foreign countries that people look to for answers and
information. Having the coordinator linked with the White House
monitoring these activities for State, USAID and the Department of
Health and Human Services will allow resources to be marshaled in a way
that direct the greatest amount where they are needed most, and reduce
the amount of resources that are underutilized or wasted. The
coordinator's position needs to be closely linked to the Secretary of
State, as well as to the White House National Office on AIDS Policy.
Having traveled to the southern regions of Africa in the early
'90s, we were not prepared to see the rates of HIV rising in the
countries we visited last year. The HIV epidemics were well defined in
the early '90s and we felt that the emphasis on prevention would have
led to either a stabilization or a decrease in the HIV epidemic.
However, when we visited Mozambique, South Africa, and Botswana we saw
that their HIV incidence rates continue to climb. We had to ask
ourselves why. On our return we looked at data throughout the entire
continent and found that there was one glaring exception to these
rising rates, and that was Uganda.
Consequently, we put together two groups to visit Uganda, once in
August and then again in December 2002, where we tried to carefully
examine the US role as well as the role of the Ugandan government in
combating HIV/AIDS. It is quite a story, and little wonder why the
President in his State of the Union address singled out Uganda as a
model country that we should examine carefully and follow. Many of you
are aware of the story of Uganda and others here may highlight it as
well, but I would like to share a few observations.
It is a relatively poor country, not unlike many of its neighboring
African countries. We in the US spend on AIDS alone roughly forty times
per capita what Uganda spends on all healthcare issues facing their
citizens. They have a declining HIV epidemic; in the United States we
either have a stable or rising HIV epidemic. Compared to South Africa,
HIV trends are going in opposite directions.
They have promoted a traditional message of celebrating virginity
at marriage, encouraging young people to be abstinent until marriage
and then asking those who are married to be faithful to their partners,
with little emphasis on condom promotion (what has become known as
their ABC message). They have had some success in highly targeted
condom campaigns, and no documented success in broader condom
campaigns. America needs to become known as the biggest promoter of the
A and B of ABC, not known as we are now as the biggest provider of C.
Uganda's message contrasts sharply with the messages given out in
the southern part of Africa. There the dominant and primary message has
been the promotion of condoms. We saw this in the early '90s and were
surprised to see an even greater emphasis on our return trip last year.
Very few government funded programs focus on abstinence or
faithfulness, and certainly most US sponsored programs, whether
government or private, focus on the broad social marketing of condoms.
There is some emphasis on diagnosis, but even that is often anonymous
in nature.
I would like to draw an analogy to what has happened in Africa
regarding these two different approaches. It is as if a large group of
experts have proclaimed a new method should be promoted regarding the
teaching of reading skills. These experts have said this approach will
help people read much better.
However, the more the new program is promoted, the worse the scores
have gotten. But even though the results are abysmal, it's as if no one
wants to stop and say that reading scores have declined and not gotten
better. Yet in this one country that has pursued a more traditional
approach, the scores have gotten incredibly better. It is very
difficult to comprehend why we can't take a few steps back and look at
the results of these two different approaches. One is highly effective;
one is not. We need to pursue the one that is highly effective and
either discontinue or highly modify the one that is not. It's really
that simple. And we must allow faith-based groups to promote abstinence
and be faithful without coercing them to also promote condoms which,
unfortunately, happens all too often.
I'd like to also share with this committee that over the years we
have sought to help families affected by HIV here in the United States
and abroad. In Africa we not only support families and orphaned
children, but we are helping fund a drug trial in Malawi that is
looking at mother to child transmission in the context of the whole
family. As we pursue trials, it is important to remember that the
husband is the primary breadwinner and that without him the health of
the mother will decline more rapidly and the children will become
orphans more quickly. Consequently, the treatment program under trial
through the Children's AIDS Fund is intended to save the whole family
and offers a treatment regimen to the husband as well as the wife and
children. And it also addresses other health related matters, which we
feel is important in structuring all HIV treatment programs abroad.
In closing I would like to share that HIV/AIDS treatment and
prevention are critically important for underdeveloped countries.
Better prevention messages will ultimately result in less demand for
treatment and less suffering from the consequences of HIV infection. We
should remember that the biggest predictor of any sexually transmitted
disease is the number of lifetime partners; the more partners the more
risk, fewer partners less risk, and one uninfected partner in a
faithful relationship virtually no risk. The President has it right,
Uganda can teach us many important lessons.
Mr. Bilirakis. Ms. Barry.
STATEMENT OF DONNA J. BARRY
Ms. Barry. Thank you very much, Chairman Bilirakis and
Ranking Member Brown and the other members of the Health
Subcommittee for being here today and for holding the hearing.
And I'll just repeat a few of the things that I've given out in
my written statement, as I think that they really do bear--
they're important enough to read and also to hear.
So I just want to say that even on a day like today as a
nurse practitioner, as a U.S. citizen, I think I can't really
think of anything more important to speak about you with you
today. And just to repeat--I won't repeat all the statistics
that have been listed already today, but I do want to say that
everybody 8,000 people are currently dying of AIDS and 5,000
are dying of tuberculosis. And it's the sad irony is that these
are absolutely presentable and treatable diseases.
I do want to applaud the administration and President Bush
for announcing the $15 billion. We have been woefully
parsimonious in our support over the past 15 to 20 years and I
think that this is a promising start.
The rhetoric now being shared on the world stages is that
we need $14 billion a year to treat all of these diseases
sufficiently and I think we need to look at the $10 billion is
being bandied about for what we need for HIV/AIDS and everyone
seems to think that this is a very large amount of money and
that, in fact, there's no way to come up with it, but just if
you would look at my comments to see how reasonable this
actually really is. It really only amounts to $35 per U.S.
citizen per year.
I'd like very much to make a strong statement that more of
the money from those $15 billion should be given to the Global
Fund. We have some very small, but very successful pilot
projects in many of the countries around the world and the
Global Fund right now is the only agency with the resources and
the capability to scale up these projects. It's a multilateral
agency. They coordinate all the different sectors in each
country and some questions have been raised about how well this
money will be tracked or how well we'll be able to monitor the
use of these funds, but Richard Feachem has a public health
background, he has a World Bank background and he set up some
of the most rigorous monitoring mechanisms for this money that
have ever been used in public health. In fact, in Haiti, we
have had more monitoring visits to our project down there than
we've ever had before since the announcement of our grant was
made. And yet, we haven't even gotten the money yet. So I think
that we can see that these funds are going to be monitored
very, very closely.
I also want to emphasize that we really need to work with
all sectors and this is the approach that the Global Fund is
taking. In Haiti, we just want to expand from 400 patients to
5,000 patients, but in order to do that we have to work with
nongovernmental organizations, we have to work with the public
health sector, the government public health sector. Without
this, there's no way that we can expand the treatment. There's
no way we'll be able to expand the treatment to 2 million
patients which the Secretary mentioned.
Bilateral aid has never been sufficient to support large
scale projects like this and it will not be sufficient through
these initiatives as they've been announced today. That's why
the Global Fund is so important and in addition, bilateral aid
rarely links tuberculosis and HIV.
I'd like to caution us from using the ABC model too widely
as we've heard today. I think that we really don't have the
evidence that this is an appropriate model for other countries
in the world and I think it also does not address other
problems, other ways that HIV is spread such as through IV drug
use.
I'd also--the last thing that--one of the last things I'd
like to say is we'd like very much to see at least some more
tuberculosis money going through the Centers for Disease
Control, the CDC. They do excellent work internationally and to
my knowledge they do not receive direct funding to work
internationally on tuberculosis. In fact, they usually always
have to ask for that money from USAID which of course adds an
additional layer of bureaucracy and less funding for the actual
programs.
Our past interventions through USAID, through other
mechanisms have not been very successful in stemming the
diseases. This is clear to everyone. Rates are still growing
around the world. And one of the things that Partners in Health
and myself advocate is that these are very complex problems.
There are not simple solutions. There are no simple solutions.
We can't just throw a simple solution at this and expect it to
work. As previous public health programs has, such as
vaccinations, which are very important, but these requires
developing infrastructure in these countries, upon which we can
build other programs. So if we set up the infrastructure to
treat HIV/AIDS, we'll also be able to treat the tuberculosis.
We'll also be able to treat other problems and solve other
problems like infant mortality, treating diabetes,
hypertension, etcetera.
But my most important message is that we've got to do this
rapidly and we've got to do it now. We don't have the time to
wait because millions are dying every month.
Thank you.
[The prepared statement of Donna J. Barry follows:]
Prepared Statement of Donna J. Barry, Partners In Health
Thank you Chairman Bilirakis, Ranking Member Brown, and the other
members of the Energy and Commerce Health Subcommittee for holding
today's hearing. And thank you very much for the opportunity to speak
at this hearing on HIV/AIDS, TB and Malaria: combating a global
pandemic. I am the director for Russia programs at Partners In Health
(PIH), a Boston-based NGO, and also work in our tuberculosis and HIV
treatment projects in Haiti and Peru. As a nurse practitioner with a
degree in public health and as a concerned citizen, I can think of
nothing more important to speak with you about today, even as we are on
the brink of war. Today there are 300 million infections from malaria
each year, 3.7 million persons newly infected with tuberculosis (1/3 of
the world's population is already carrying the TB bacteria), and 42
million persons living with HIV, and the numbers continue to grow. In
2002, 3.1 million people died of AIDS; tuberculosis accounted for 2
million deaths and malaria killed more than 1 million people. 8000
people die every day from AIDS . . . 5000 from TB. The sad irony of
these statistics is that these are treatable diseases.
During President Bush's State of the Union speech on January 28, he
announced a $15 billion dollar five-year plan to battle HIV/AIDS and
this is to be applauded. As a country we have been woefully
parsimonious with our support to fight this plague and in the mean time
cases and mortality from the disease have continued to increase
worldwide. Experts conservatively estimate that we need at least $14
billion per year in order to contain these diseases worldwide: 10
billion for HIV/AIDS and an additional 4 billion for malaria and TB.
While 10 billion dollars seems like a lot of money in this age of
deficits, it really is not. It is about 35 dollars per US citizen per
year; is less than 25% of the increase in the defense budget in 2002;
and is less than 1% of the tax cut we received last year. If indeed the
entire $15 billion will be new spending for HIV/AIDS, this will be a
desperately needed, though still inadequate, infusion of funding to
fight this dreadful disease. Therefore, it behooves us to spend this
much-needed money in the most effective way possible.
The first recommendation that my colleagues at PIH and I would like
to share with you today is that more of the funding should be allocated
to the Global Fund which has approved projects for funding in over 90
countries and will pay out at least $1.5 billion in the next 2 years.
Small but successful pilot projects are in place that can prevent and
treat HIV and TB. However, what is now needed is to take the projects
to scale in these countries and the Global Fund is the only agency in
the world with the resources and capability to fund and direct such
expansion. Moreover, the Global Fund is a Multilateral and coordinated
effort that works both through ministries of health and NGOs. The
current head of the Global Fund, Richard Feachem is a physician with a
public health background and experience at the World Bank and as such
has set up some of the most rigorous monitoring mechanisms for this
money that have ever been used in public health. Each proposal that has
been approved has been developed by a Country Coordinating Mechanism, a
consortium of those involved in the prevention and treatment of disease
from both the public and private sector. This mechanism is removed from
government bureaucracy and politics and is focused only on the use of
global fund monies in in-country projects.
In our project in Haiti, we are currently treating 400 patients
with Highly Active Anti-Retroviral Therapy (HAART)--one of the largest
treatment projects in a developing country. Haiti's application was one
of the first to receive Global Fund approval, and in this proposal it
is planned to expand this treatment to 5,000 patients. In order to do
this, we will need to work with all sectors' not only with community-
based NGOs and not only with government entities. It will be important
to integrate all of the resources that each sector can contribute. Bi-
lateral aid through USAID has never had adequate resources to support
large-scale projects of this sort. This, in fact, is why the Global
Fund was created and these types of projects are clearly the next phase
of fighting these diseases. In addition, few, if any, bi-lateral
projects have attempted to link or combine prevention and treatment
services for TB and HIV, which is critical in order to control either
disease. I'm pleased to hear that language already being discussed in
the House and the Senate also includes funding for tuberculosis. The
Fund has a specific category of proposals for those countries that wish
to apply for joint funding for TB and HIV programs.
Secretary Thompson is currently the Chair of the Fund and as such
will have the ability to oversee these projects and ensure their
success. I hope that you will consider allocating more funding to the
Global Fund as the members of the International Relations Committee
recently did. Their plan would authorize the president to contribute up
to $1 billion per year to the Fund and we strongly encourage you follow
their lead, if not exceed this amount. However, I would be cautious in
using the ABC model too widely as I understand the International
Relations Committee is recommending as we do not yet have published
data to show that this model is what caused the decline in transmission
of HIV in Uganda and it does not address the spread of HIV through IV
drug-using populations which is contributing to the sky-rocketing rates
of HIV incidence in countries of the former Soviet Union.
If, as many of the news reports and press releases from the
government have recently stated, the majority of this $15 billion
dollars will be spent through bi-lateral mechanisms, we would like to
encourage that this funding for tuberculosis and HIV/AIDS be shared
with both the U.S. Centers for Disease Control and Prevention (CDC) and
the U.S. Agency for International Development. The CDC receives no
direct funding for their outstanding work on tuberculosis
internationally. They are required to request funding from USAID in
each country where they work. This adds an additional layer of
bureaucracy which subtracts from the amount of funds available for
actually treating and preventing HIV and TB.
In addition, the CDC has a proven track record of implementing
programs in both tuberculosis and HIV/AIDS in the United States and
many other countries around the world. They have extensive networks of
health care providers, laboratory experts and researchers who directly
implement programs rather then contracting them out to other
organizations. They have experience working with both governmental and
non-governmental organizations which as I stated above, will be
critical to the success of large-scale expansion projects which are so
important today. Our projects in Peru, Russia and Haiti are engaged in
successful collaboration with projects from CDC and they are the most
expert at coordinating work at the level of ministries of health.
I'd like to finish by stating that while US government funding for
HIV/AIDS through USAID remained steady, albeit too low, during the
nineties, and has increased in the past few years, we have seen little
progress in abating the spread of disease, and implementing adequate
treatment programs. In addition, USAID funding for tuberculosis has
steadily increased from 1998, but cases continue to rise across the
world. Some progress has been seen in select countries, but by no means
can we say the there are positive trends in stemming either of these
diseases.
With the additional resource allocation from this Administration,
we need to fundamentally rethink the way that we are approaching these
complicated health epidemics and rapidly build on the successes which
have been achieved. Public health can no longer focus solely on
strategies of prevention and ``one shot deals'' such as vaccination
programs. We need to use the grim statistics of the HIV and TB
epidemics to rise to the moral challenge before us. That is to truly
build and develop the health infrastructure to deal with complex
diseases that require treatment, monitoring, and laboratories. This
approach, one of tackling the complex health interventions that face us
today, will lead not only to the needed impact in the AIDS and TB
epidemics, but improvements in other more complex public health
challenges from decreasing maternal mortality--which requires blood
banking and cesarean section to treatment of patients with diabetes and
hypertension. We cannot do this only through bi-lateral aid, the world
needs to coordinate its efforts. Successful pilot projects that
demonstrate an evidence-based, data-driven sound program on which to
build must be expanded. New projects must be started. The AIDS and TB
epidemics will not wait . . . we must move quickly to begin treating
the millions of patients who are waiting before millions more perish
before our eyes. Thank you.
Mr. Bilirakis. Thank you, Ms. Barry.
Ms. Monico.
STATEMENT OF SOPHIA MUKASA MONICO
Ms. Monico. Thank you, Mr. Chairman, ladies and gentlemen,
for giving me the opportunity to be with you today to talk
about the global HIV/AIDS pandemic. I am a native Ugandan and
currently working with the Global Health Council. The Global
Health Council is the world's largest membership alliance
dedicated to saving lives by improving health around the world.
From 1995 to 2001, Mr Chairman, I was the Executive
Director of The AIDS Support Organization, TASO. TASO was
founded in 1987 to contribute to the process of restoring hope
and improving the quality of life of persons and communities
infected and affected by HIV and AIDS. TASO is now recognized
around the world as a leader and innovator in the field of AIDS
care and support. And this includes prevention and treatment of
TB and malaria.
I would like to begin my task by taking advantage of this
opportunity and on behalf of the Africans, and my country,
Uganda, thank the U.S. Congress for their efforts to increase
the U.S. government's spending on global AIDS programs.
In addition, I would like to thank the Americans and
President Bush for the Emergency Plan for AIDS Relief in Africa
and the Caribbean.
Americans have made a commitment to addressing the global
AIDS pandemic because they have seen the programs in place that
work. The best example of this is my country, Uganda. Everybody
has been talking about Uganda which is now considered to be one
of the world's earliest success stories in our attempts to
control the HIV and AIDS pandemic. Uganda has been successful
due to several important factors, Mr. Chairman, including
strong political leadership, a comprehensive prevention program
and a resilient community that has formed itself into
community-based care organizations to look after people living
with HIV and AIDS such as TASO.
In 1986, when President Yoweri Museveni came to office, he
realized that HIV and AIDS was ravaging our country. Early on
in his presidency, Mr. Museveni spoke out about HIV and AIDS
and became an early advocate for reducing the stigma associated
with HIV/AIDS. And this strong political leadership was key to
Uganda's success. But ladies and gentlemen, a reduction in
stigma is not enough to halt HIV transmission. Individuals must
take action to change their own behavior and take precautions.
Early on in his campaign, President Museveni spoke out candidly
and often about the need for individual Ugandans to protect
themselves from the virus. Working with nongovernmental and
community-based organizations, President Museveni promotes
prevention interventions that are creative and culturally
appropriate. For some, he promotes a message of delaying sexual
debut; for others, he urges them to be faithful to their
partners and where all fails, to consistently and appropriately
use the condoms. It is this three-part comprehensive prevention
message and the message to compassionately care and support our
beloved ones that contributes to the relatively small, but
significant success in Uganda.
I cannot stress strongly enough that all these program
elements need to be in place for prevention to work. As a
Ugandan, I am deeply concerned when I hear people talking about
a single element of our successful national program, for
example, abstinence, which is always out of context and ascribe
all our achievements to that one element. They all must be
implemented together in order for prevention to work.
Mr. Chairman, in Uganda, we know that it is important to
take into account the ever increasing impact that the epidemic
is having on women and girls. A key component is the
integration of HIV prevention and care interventions in
existing infrastructure such as the traditional family planning
services. In rural areas of Uganda, this is a critical way for
women to learn about HIV and AIDS in an accommodating and
unstigmatized way so that they can take appropriate action to
protect themselves and their children from the virus.
Integration is an efficient and effective way of getting HIV/
AIDS to be in malaria services to those in rural areas, cost
effectively and without duplication and in a very coordinated
way.
Targetting youth, Mr. Chairman, is also critical to the
success of programs in Uganda. Since 1989, schools have
integrated HIV education and behavior changing messages into
the curriculum. It is called ``life skills education'' and not
abstinence education. Unlike past programs, this sexuality
education not only targets girls, but it also targets boys to
be part of the solution.
Ladies and gentlemen, Ugandans have given substantial
attention to education as we believe that youth friendly
approaches, candidly promoting efficient integration of
appropriate HIV/AIDS related information, education and
communication, as well as a protective environment contributed
to our reported increase in delayed sexual debut.
We have also made special efforts to establish programs
that provide care and support for pregnant women. Uganda is one
of the target countries in the President's MTCT initiative that
has been a model in terms of providing care for pregnant women.
Mr. Bilirakis. Please summarize, if you could, ma'am.
Ms. Monico. Yes, in 1 minute.
Mr. Bilirakis. Do the best you can. Don't take away from
your message.
Ms. Monico. I'll try to be very fast. One key aspect of
MTCT program is the inclusion of voluntary counseling and
testing. Hundreds of thousands of women have received prompt
care and have avoided infecting their newborns due to this
important intervention.
Many of these programs have been established in conjunction
with existing family planning and maternal health clinics as
women already access services through these outlets. This
collaboration is critically important to ensure that those most
in need continue to have access to services at the most
appropriate locations.
In Uganda, due to the high incidence of HIV, it was
critical that the country also develop a strong care and
treatment component. By working with strong nongovernmental
organizations, faith-based organizations and community-based
support groups, flexible, creative and culturally appropriate
interventions were put in place to provide care and support to
those living with AIDS. TASO is an example of this.
But Mr. Chairman, what we have to realize is that it's
relatively low technology and low cost care interventions that
have an enormous impact on the lives of those living with HIV/
AIDS and in conclusion the next steps in addressing the
epidemic in Uganda and around the world is extending
antiretroviral treatment in the developing countries. These
medications will provide hope to the millions of Africans who
do not see a future for themselves or for their communities
today. Treatment is not only a humanitarian imperative.
Treatment supports prevention efforts by encouraging
individuals to learn their HIV status and reduce the stigma to
the disease.
Mr. Chairman, AIDS is not inevitable. We have learned a
great deal over the last 20 years. It is our common
responsibility to address AIDS with a clarity of vision of what
we have learned and what works, a comprehensive approach based
on the reality of people's lives rather than an external view
of how people ought to behave is the right prescription for
bringing an end to this tragedy.
Thank you.
[The prepared statement of Sophia Mukasa Monico follows:]
Prepared Statement of Sophia Mukasa Monico, Global Health Council
Thank you for giving me the opportunity to be with you today to
talk about the global HIV/AIDS pandemic. I am a native Ugandan and am
currently, the Senior AIDS Program Officer at the Global Health
Council. The Global Health Council is the world's largest membership
alliances dedicated to saving lives by improving health around the
world.
From 1995 to 2001, I was the Executive Director of The AIDS Support
Organization (TASO). TASO was founded in 1987,to contribute to the
process of restoring hope and improving the quality of life of persons
and communities infected and affected by HIV/AIDS. TASO is now
recognized around the world as a leader and innovator in the field of
AIDS care and support.
I would like to begin my task by taking advantage of this
opportunity and on behalf of Africans, and my country Uganda thank the
Americans and President Bush's for the ``Emergency Plan for AIDS Relief
in Africa.''
The proposal outlined in the State of the Union message January 28
was substantial and meaningful--President Bush portrayed how the
American compassion must extend far beyond your own shores, to include
the men, women and children living with HIVAIDS in the developing
world. The President's challenge and the venue through which it was
delivered, will go a long way towards increasing American public
support for our efforts to fight the human and social devastation
caused by AIDS. The onus is now on the Africans and Caribbean to make
it work for us, and we look forward to working with the Administration
and Congress as this plan is put into action.
WHAT IS AT STAKE?
20 years ago most of the world was ignorant about the evolution of
the HIV/AIDS epidemic and how best to respond to it. In 2003 we know
AIDS is like a forest fire that is consuming entire countries and must
be stopped.
Especially in developing countries, HIV has moved beyond the realm
of public health alone and is now a social, economic and security
concern.
Since the epidemic began, more than 60 million people have been
infected with the virus. It is projected that 200 million people will
be infected in 15 years. HIV/AIDS is now the leading cause of death in
sub-Saharan Africa and the fourth-largest killer worldwide. To date,
AIDS has claimed over 22 million lives.
Today, over 42 million people are living with HIV/AIDS. Ninety five
percent of the people with HIV/AIDS live in countries with the least
resources and two-thirds of them are in Sub Saharan Africa.
People, families, societies, economies and nations are at risk
today--and the risk stems primarily from the likely impact of millions
of premature deaths within the next decade among those already
infected. Only treatment can alter the trajectory. Moreover those
countries with the highest rates of infection are at disproportionately
greater risk, which makes treatment there all the more important.
For years, observers have expected the epidemic in Africa to
plateau. Yet, each year, the news grows bleaker, as infection rates
exceed levels previously thought possible.
In Botswana, the nation with the world's highest infection rate,
median HIV prevalence among pregnant women in urban areas increased
from 38.5 percent in 1997 to 44.9 percent in 2001. Likewise, in
Zimbabwe, Namibia, and Swaziland--where infection rates rival those of
Botswana--HIV prevalence continues to increase. In South Africa, in the
past ten years, HIV prevalence among pregnant women rose from less than
one percent to 25 percent.
After years of relatively slow increases in West Africa, infection
rates appear to be rising sharply in Cameroon (from 4.7 percent
prevalence in urban populations in 1996 to national prevalence of 11
percent among pregnant women in 2000) and in several districts in
Nigeria, the continent's most populous country.
The rate of increase in HIV infections is the highest in Russia and
the republics of the former Soviet Union. In Russia, the number of
cases rose from just under 11,000 in 1998 to 147,000 by late last year.
Prevalence is also increasing in Asia. In India, some 4 million people
are infected with the virus, one Indian is getting infected every
minute, making India the second largest HIV infected country in the
world after South Africa.
HIV also continues its relentless assault on the Caribbean, the
world's second most affected region, where HIV prevalence in at least
two countries already exceeds 4 percent. The number of people infected
grew by nearly 20 percent in North Africa and the Middle East last
year, leaving close to half a million people with HIV / AIDS.
WHAT IS THE EFFECT?
In its 22 years' course, the HIV/AIDS epidemic has already wiped
out more than 50 years of development gains in the hardest-hit
countries by cutting short life expectancy, in some cases by more than
20 years.
One of the most immediate humanitarian concerns in the wake of the
HIV/AIDS epidemic is children. In 2002 alone, more than 600,000
children below the age of 15 died from AIDS, most of them infected at
birth through transmission from their infected mothers. 800, 000 below
the age of 15 were newly infected in 2002.
Equally startling is the situation of children orphaned by AIDS.
Now counting 14 million, the majority live in sub-Saharan Africa, many
in areas struck by food crisis and violent conflict or political
disturbances. Making ends meet for these children often means forsaking
school and engaging in risky activities for survival, such as
transacting sex in exchange of food, shelter and protection. Even in
areas where positive signs of reduced incidence of HIV among young
people have been registered, such as in Uganda, already existing high
prevalence rates make the number of orphans set to increase as death
rates in AIDS rise. The number of children who have lost one or both of
their parents to AIDS is set to double to almost 25 million over the
next decade. Providing them with reliable protection and safe schooling
is the best social vaccine to prevent them from also falling prey to
AIDS.
More and more, AIDS is attacking young people. Almost half of the
14,000 people newly infected each day are of a young age and altogether
some 12 million young people are currently living with HIV/AIDS. The
future course of this global epidemic and its links to human security
depends on whether the world can protect young people and children
everywhere from the devastating effects of the HIV/AIDS epidemic.
Saving future generations calls for more investment in the current
prevention, care and treatment interventions as well as research and
development into new ones, especially those that can be controlled by
women.
Saving people is a humanitarian imperative. Saving development is a
political imperative. In 2005, a target year for implementing the
Declaration of Commitment on HIV/AIDS, world leaders will have to look
into the mirror of accountability and prove that rhetoric has been
followed by action.
WHAT WORKS?
But it is critical that we look beyond the numbers and begin to
examine programs that have worked so that these lessons learned can be
applied in other countries. No one country in the developing world has
established an HIV/AIDS program that has shown total success. But those
programs that have been successful in provinces or cities have
reflected the needs of their community, are implemented by members of
the community, and include elements across the continuum of prevention,
care and treatment. Some are run by non-governmental organizations and
others are run by Ministries of Health--some focus on preventing the
spread of the disease while others provide needed palliative care--and
others are beginning to provide much needed hope for people living with
AIDS by providing treatment.
Prevention, care and treatment serve overlapping but not identical
goals. Prevention and care efforts are not additive but rather each
strategy increases the impact on the other through synergistic effects.
Further, prevention and treatment involve different sectors and
constituencies. It is therefore, necessary to invest in all
simultaneously to achieve more than would be accomplished by investing
in any alone.
Prevention
Today, prevention efforts reach fewer than 1 in 5 of those at risk.
To have an impact on the future course of the epidemic, pockets of
success and pilot prevention projects must rapidly become comprehensive
programs that reach all those at risk, and obstacles to prevention must
be swiftly addressed and overcome.
HIV transmission can be reduced through a wide range of proven
behavior change programs that encourage people to:
delay initiation of sex;
reduce their number of partners;
use a condom;
seek treatment of sexually transmitted diseases; and
make use of expanded voluntary counseling and testing
programs.
Another key prevention strategy is to reduce the transmission of
HIV from mother-to-child. The risk of mother-to-child HIV transmission
can be reduced by half or more with:
short courses of antiretroviral drugs,
voluntary counseling and testing, and
enhanced reproductive health services.
Effective HIV prevention involves a carefully planned combination
of these interventions, reinforced by public policies to combat the
social factors that facilitate HIV transmission.
Care
What makes AIDS uniquely destructive is that it targets adults in
the prime of their lives--when they are workers, parents and
caregivers. Treating those living with HIV, therefore, saves children
from becoming orphans, keeps household and businesses in tact,
maintains social cohesion, and enhances the return on social
investments in sectors such as education and rural development.
Proven care programs include many different components. They must
include the medical treatment of sexually transmitted diseases and
opportunistic infections. But, they cannot stop there. They must also
include psychosocial support and nutritional support.
Treatment
In low- and middle-income countries access to anti-retroviral
treatment is available to less than five percent of those in need. In
Africa, no more than one percent have access to treatment.
Treatment will add years of quality life--which has no price--and
saves the health system of even the poorest country several hundred
dollars per patient per year in averted palliative and opportunistic
infections car. As a single example, an analysis from Namibia, a
country with one of the highest HIV rates in the world, found that the
provision of HIV care including HAART for all in need, would increase
per capita output above the per capita taxes required to fund such a
program,
While medical advances have sharply reduced HIV-related death and
sickness in industrialized countries, the epidemic continues on as
before in developing countries, harming families, burdening the most
vulnerable, and robbing entire regions of hope for the future.
The glaring inequality between developed and developing countries
in terms of access to anti-retroviral care is unacceptable in an era
when treatment regimens exist and are known to reduce suffering and
improve the quality of life, to prolong lives and productive life-
cycles, and to cut hospitalization costs--all of great benefit to
households and communities, to economic and national development, to
political stability and human security.
WHAT IS NEEDED FOR SUCCESS?
UNAIDS and others have studied countries where HIV prevention,
care, treatment and support programs have been most successful and
identified common characteristics, these include;
Strong leadership, including visible ownership by national
leaders of the fight against the disease;
Broad awareness of HIV/AIDS among the general population
Open discussion of sex and a national commitment to sex and
sexuality education for youth;
Active involvement of all sectors, including civil society,
religious leaders, and non-governmental organizations;
Concerted efforts to reduce AIDS stigma, and policy and legal
changes to prevent HIV-related discrimination; and
Availability of external assistance in the financing,
development, and implementation of effective prevention
programs.
THE UGANDA EXAMPLE
Uganda is now considered to be one of the world's earliest success
stories in our attempts to overcome the HIV/AIDS pandemic. Uganda has
seen substantial declines in prevalence, and incidence of HIV/AIDS
within the past decade, especially among young people. Uganda was
successful due to several important factors, including strong political
leadership, a comprehensive prevention program, and community based
care programs such as the one that I ran at The AIDS Service
Organization. Treatment was not part of the Uganda success story as the
cost of anti-retroviral medications makes them unavailable.
In 1986, when our new President Yoweri Museveni came to office, he
realized that HIV/AIDS was ravaging our country. Early on in his
presidency, President Museveni spoke out about HIV/AIDS and became an
early advocate for reducing the stigma associated with HIV/AIDS. This
strong political leadership was key to Uganda's success. This reduction
of stigma is critical on many levels. When stigma is reduced,
individuals are more willing to seek counseling and get tested to learn
their HIV status. If stigma is reduced in communities, they become more
accepting of those who are positive and are therefore willing to become
involved in their care as well. Reducing stigma has benefits for both
the community and the individual. When stigma is reduced, an individual
is more willing to be tested and therefore is able to take steps to
avoid transmission of the virus. This is adds to the overall success of
a prevention effort
But, a reduction in stigma was not enough to halt HIV
transmission--individuals must take action to change their own behavior
and take precautions. Early on in his campaign, President Museveni
spoke out loudly and often about the need for individual Ugandans to
protect themselves from the virus. Working with non-governmental and
community-based organizations, President Museveni promoted prevention
interventions that were creative and culturally appropriate. For some,
he promoted a message of delaying sexual debut; for others, he urged
them to be faithful to one partner and to use a condom. It was this
three-part message that was effective in Uganda. In my personal
experience, I believe that this three-part message is critical.
Different populations require different messages and it is critical
that people of all ages are educated about how to protect themselves.
I can not stress strongly enough that all these program elements
need to be in place for prevention to work. As a Ugandan, I am deeply
concerned when I hear people taking a single element of our successful
national program--for instance abstinence--out of context and ascribe
all our achievements to that one element. They all must be implemented
together in order for prevention to work.
In Uganda, we knew that it was important to take into account the
ever increasing impact that the epidemic was having on women and girls.
The low social and economic status of women, driven by the cycle of
poverty, often makes it difficult for women to assert themselves and
Uganda took several steps to improve their status, including
instituting a requirement that a specific percentage of the Parliament
should be female, providing microcredit programs to allow women to gain
economic self sufficiency. One other key component was the integration
of HIV prevention messages into traditional family planning services.
In rural areas of Uganda, this was a critical way for women to learn
about HIV/AIDS so that they can take appropriate actions to protect
themselves from the virus. Integration is an efficient and effective
way of getting HIV/AIDS services to those in rural areas quickly and in
settings where men and women are already accessing services.
Targeting youth was also critical to the success of programs in
Uganda. Since 1989, schools have integrated HIV education and behavior
changing messages into the curriculum. They are called ``life skills
education'' because without this information and skills about how to
protect themselves from HIV, they will not survive in an African
country with the HIV incidence rate found in Uganda. Unlike past
programs, this sexuality education not only targeted girls but it also
included formal information to boys about how they can be part of the
solution. Ugandans have given a lot of attention to education as we
believe that youth friendly approaches candidly promoting appropriate
and efficient integration of the information into education and
communication contributed to a reported increase in delayed sexual
debut.
Special efforts were also made to establish programs to provide
care and support for pregnant women. Uganda is one of the target
countries in the President's mother-to-child transmission (MTCT)
initiative and has been a model in terms of providing care for pregnant
women. One key aspect of MTCT programs is the inclusion of voluntary
counseling and testing. Through this counseling, a mother learns her
HIV status in order to assure that the appropriate precautions will be
taken during birth to limit HIV transmission to her newborn. Hundreds
of thousands of women have received care and HIV transmission has been
blocked to their newborns due to this important intervention. Many of
these programs have been established in conjunction with existing
family planning and maternal health clinics as women already access
services through these outlets. This collaboration is critically
important and will assure that those most in need continue to have
access to services at the most appropriate locations
In Uganda, due to the high incidence of HIV, it was critical that
the country also develop a strong care and treatment component. By
working with strong nongovernmental organizations, faith based
organizations and community based support groups, flexible, creative
and culturally appropriate interventions were put in place to provide
care and support to those living with AIDS. TASO is an example of an
organization that has successfully provided care to those living with
AIDS for many years. The key components of our program included:
Medical care to treat opportunistic infections;
Preventative therapies in order to avoid the complications
from AIDS;
Supportive counseling and psychosocial support;
Health education;
Family planning so that women can make their own decisions
about future child-bearing; and
Nutritional support.
These are relatively low tech and low cost interventions that have
an enormous impact on the lives of those living with HIV/AIDS.
In addition, you will note that these interventions represent a
multi-sectoral response. AIDS is not just a medical condition for those
living in Africa who do not have access to treatment. It must be
addressed from a social, economic and medical perspective in order to
have an impact on those communities that are most affected.
The next step in addressing the epidemic in Uganda and around the
developing world is extending anti-retroviral treatment to the
developing world. In his State of the Union address, President Bush
outlined his vision and he committed the United States to expanding
access to anti-retrovirals. These medicines will provide hope to the
millions of Africans who do not see a future for themselves or their
communities today. Pilot projects in Africa have begun to see results
and people are returning to their previous lives as working and self
sufficient members of society. Treatment is not only a humanitarian
imperative--treatment supports prevention efforts by encouraging
individuals to learn their HIV status and reducing the stigma of the
disease.
AIDS is not inevitable. We have learned a great deal over the last
twenty years. It is our common responsibility to address AIDS with the
clarity of vision of what we have learned and what works. A
comprehensive approach, based on the reality of people's lives rather
than an external view of how people ought to behave is the right
prescription for bringing an end to this tragedy.
Mr. Bilirakis. Thank you so very much.
Dr. Green, please proceed,sir.
STATEMENT OF EDWARD C. GREEN
Mr. Edward Green. Thank you, Mr. Chairman and distinguished
members of the Health Subcommittee. I'm the Senior Research
Scientist at the Harvard School of Public Health. For most of
my professional career, I've worked in less developed countries
as a behavioral science research and designer and evaluator of
public health programs. I've worked extensively in Africa and
other resource poor parts of the world. A great deal of my work
is focused on reproductive health and some of this including
the social marketing of condoms.
In view of all the sad news we hear about AIDS, especially
in Africa, it is my pleasure to share some good news. We've
already heard some of it. There are several bright spots in the
world when it come to AIDS an the brightest spot of all my be
Uganda where infection rates have declined nationally from 21
percent to 6 percent. You heard 30 percent earlier, that would
be for urban areas.
The government of Uganda, led by President Museveni,
developed a distinction approach to AIDS prevention known as
the ABC approach. You've already heard what that is. The
abstinence message for the most part took the form of urging
youth to delay having sex until they were older and preferably
married. Many of us in the AIDS and public health community
didn't believe that abstinence or delay and faithfulness were
realistic goals. And it seems we were wrong.
Uganda's program began in 1986, the year President Museveni
became head of state. Since the rate of new infections began to
decline in the late 1980's, it becomes important to know which
programs were in place in the latter 1980's and what behaviors
changed in order to account for the decline in infection rates.
The standard programs we associate with AIDS prevention were
not in place in the 1980's.
We now know that there were significant changes in sexual
behavior between 1989 and 1995. And these were most pronounced
among youth, the very age group primarily targeted by AIDS
education and the behaviors that changed the most were the ones
emphasized in Uganda's AIDS prevention efforts.
Let me share with you some World Health Organization data
we have on some of the key measures of sexual behavior.
The first pertains to premarital sex. The proportion of
young males age 15 to 24 reporting premarital sex declined from
60 percent in 1989 to 23 percent in 1995. For females, the
decline was from 53 percent to 16 percent.
Now looking at all age groups, 41 percent of males had more
than one sex partner in 1989. This declined to only 21 percent
by 1995. For females, the decline was from 23 percent to 9
percent.
Now we can compare this with data on condom use. In 1995,
about 6 percent of sexually active Ugandans used a condom with
some regularity, according to the U.S.-funded Demographic and
Health Survey. By 2000, this rose to 11 percent of sexually
active Ugandans or 8 percent of all Ugandans. However, these
low figures obscure the fact that condom use has become quite
high among those who need them most, namely those relatively
few who are still having multiple sexual partners. The ABC
approach recognizes that some people cannot or will not avoid
risky sex, or some are already infected, so they need to reduce
their risk with condoms.
What prevention programs existed in the latter 1980's?
There was a deliberate attempt to fight stigma and
discrimination associated with AIDS and to generate open and
candid discussion about the epidemic everywhere, down to the
village level. It was AIDS education in the primary schools.
The faith-based organizations were involved from the beginning
of the national response and they were particularly adept at
promoting the abstinence and faithfulness message.
The AIDS message was not soft-petaled. People were made to
fear HIV infection, but not fear people with AIDS. People were
also told clearly what to do to avoid infection. The main
lessons from Uganda are that, one, sexual behavior can change;
two, a comprehensive program promoting abstinence, faithfulness
and condom use for nonregular partners can be implemented and
this may lead to higher levels of all three outcomes; three,
AIDS prevention programs benefit greatly from top-level
political commitment and involvement; four, condoms do play a
role in risk reduction, but focusing exclusively on condom use
is not a panacea for HIV prevention, especially in high
prevalence, generalized epidemics such as find in Africa.
It may be noted that condom user rates in Uganda are now
higher than those found in other countries, as we can see in
the figure where Uganda stands out in its relatively low levels
of multi-partner sex.
Some in the West have expressed skepticism about the
ability of African women to abstain or be faithful since women
are often thought to have little power to negotiate sex. Yet,
look at the data we have. By 1995, a great majority of Ugandan
women, 98.5 percent, were reporting either abstinence or no sex
partner outside of their regular partners. Along with the ABC
approach, the Ugandan government took various steps to raise
the status of women. One measure of the success of these
efforts comes from the Demographic and Health survey which asks
women if they believe they have the power to refuse unwanted
sex, or to insist upon condom use. Uganda ranked first among
African nations.
AIDS prevention is largely a behavioral problem that
requires a behavioral solution. I believe that AIDS prevention
programs in Africa and the developing world generally have
become too focused on medical technology and drugs, and not
enough on behavior. Evidence from Uganda and some other
countries show that when faced with a life-threatening danger,
people can and will modify their behavior, once they're given
the right information in the right way. Uganda's ABC approach,
especially as it was implemented in the early years, that
country's epidemic has proven to be an effective model that has
worked in Africa and beyond. There are other countries that
have implemented ABC approaches and they have also achieved
measures of success: Senegal, Zambia, Jamaica and the Dominican
Republic.
I see I'm out of time. I would ask that a paper that I co-
authored published by USAID called ``What Happened in Uganda''
be placed in the record.
[The prepared statement of Edward C. Green follows:]
Prepared Statement of Edward C. Green, Senior Research Scientist,
Harvard Center for Population and Development Studies
Thank you, Chairman Tauzin and distinguished members of the Health
subcommittee. I am a senior research scientist at the Harvard School of
Public Health. For most of my professional career, I have not been an
academic. I have worked in less developed countries as a behavioral
science researcher and as designer and evaluator of public health
programs. I have worked extensively in Africa and other resource-poor
parts of the world. A good deal of my work has focused on reproductive
health, some of this including the social marketing of condoms and oral
contraceptives.
In view of all the sad news we hear about AIDS, especially in
Africa, it is my pleasure to share some good news. There are several
bright spots in the world when it comes to AIDS. The brightest spot of
all may be Uganda, where infection rates have declined from 21% to 6%
since 1991 [Fig. 1 and Fig. 2].
The Government of Uganda, led by President Museveni, developed a
distinctive approach to AIDS prevention known as the ABC approach:
Abstain, Be faithful, or use Condoms if A and B are not practiced. The
abstinence message for the most part took the form of urging youth to
delay having sex until they were older, and preferably married. Many of
us in the AIDS and public health communities didn't believe that
abstinence or delay, and faithfulness, were realistic goals. It now
seems we were wrong.
Uganda's program began in 1986, the year President Museveni became
head of state. Since the rate of new infections began to decline in the
late 1980s, it becomes important to know what programs were in place in
the latter 1980s and what behaviors changed, in order to account for
the decline of infection rates. The standard programs we associate with
AIDS prevention were not in place in the 1980s.
We now know that there were significant changes in sexual behavior
between 1989 and 1995. And these were most pronounced among youth, the
very age group primarily targeted in AIDS education. And the behaviors
that changed the most were the ones emphasized in Uganda's AIDS
prevention efforts.
Let me share with you some World Health Organization data we have
on some key measures of sexual behavior.
The first pertains to premarital sex. The proportion of young males
age 15-24 reporting premarital sex decreased from 60% in 1989 to 23% in
1995. For females, the decline was from 53% to 16%.
Next, looking at all age groups, 41% of males had more than one sex
partner in 1989. This declined to only 21% by 1995. For females, the
decline was from 23% to 9%. Furthermore, the proportion of males
reporting three or more sex partners fell from 15% to 3% between 1989
and 1995.
Now we can compare this with data on condom use. In 1995, about 6%
of sexually active Ugandans, used a condom with some regularity,
according to the US-funded Demographic and Health Survey. By 2000, this
rose to 11% of sexually active Ugandans, or 8% of all Ugandans. However
these low figures obscure the fact that condom use has become quite
high among those who need them most, namely those relatively few who
are still having multiple partners The ABC approach recognizes that
some people cannot or will not avoid risky sex, and so they need reduce
their risk with condoms.
What prevention programs existed in the latter 1980s? There was a
deliberate attempt to fight stigma and discrimination associated with
AIDS, and to generate open and candid discussion about the epidemic
everywhere, down to the village level. There was AIDS education in the
primary schools. The faith-based organizations were involved from the
beginning of the national response and they were particularly adept at
promoting abstinence and faithfulness.
The AIDS message was not soft-pedaled. People were made to fear HIV
infection, but not to fear people with AIDS. People were also told
clearly what to do to avoid infection.
The main lessons from Uganda are that: (1) sexual behavior can
change; (2) a comprehensive program of promoting abstinence,
faithfulness and condom use for nonregular partners can be implemented
and this may lead to higher levels of all three outcomes; 3) AIDS
prevention programs benefit greatly from top-level political commitment
and involvement; 4) Condoms do play a role in risk reduction, but
focusing exclusively on condom use is not a panacea for HIV prevention,
especially in high prevalence, generalized epidemics as we find in
Africa.
It may be noted that condom user rates in Uganda are not higher
than those of other countries, as can be seen in Fig. 3.
CONDOM USE WITH LAST NON-REGULAR PARTNER
Where Uganda stands out is in its relatively low levels of multi-
partner sex, as seen in Fig. 4.
These figures are from a USAID report of a September 2002 Technical
Meeting on ``The ABC's of HIV Prevention'' (USAID 2002).
Some in the West have expressed skepticism about the ability of
African women to abstain or be faithful, since women often have little
power to negotiate sex. Yet look at the data we have. By 1995, the
great majority of Ugandan women, 98.5%, were reporting either
abstinence or no sex partner outside their regular partners. Along with
the ABC approach, the Ugandan government took various steps to raise
the status of women. One measure of the success of these efforts comes
from the Demographic and Health survey, which asks women if they
believe they have the power to refuse unwanted sex, or insist upon
condom use. Uganda ranked first among all African nations.
AIDS prevention is largely a behavioral problem that requires a
behavioral solution. I believe that AIDS prevention programs in Africa
and the developing world generally have become too focused on medical
technology and drugs, and not enough on behavior. Evidence from Uganda
and some other countries, show that when faced with a life-threatening
danger, people can and will modify their behavior, once they are given
the right information, in the right way. Uganda's ABC approach,
especially as it was implemented in the early years of that country's
epidemic, has proven to be an effective model that has worked in Africa
and beyond. There are other countries that have implemented ABC
approaches, and they have also achieved measures of success: Senegal,
Zambia, Jamaica, and the Dominican Republic.
What are the implications for US policy, at least in Africa? It
must be acknowledged that program emphasis on condom provision and
promotion alone does not seem to have paid off. A 2003 UNAIDS review of
condom effectiveness (Hearst and Chen 2003) concluded, ``There are no
definite examples yet of generalized epidemics that have been turned
back by prevention programs based primarily on condom promotion.''
Correct and consistent condom use surely averts infections, but after
many years of effort, most condom use in Africa remains inconsistent.
In the words of the UNAIDS review, ``There is little convincing
evidence that inconsistent condom use provides any protection.'' In
fact, the countries in Africa which have the highest levels of condom
availability relative to male population (Zimbabwe, Botswana, South
Africa, Kenya) have some of the highest HIV prevalence rates in the
world.
Average number of condoms per male 15-49 in African countries for which data are available. Source: DKT
----------------------------------------------------------------------------------------------------------------
Average Average
annual males 15-59 annual HIV
Country condoms (in thous.) condoms/ Prevalence
1989-2000 1995 male 15-59 (%)
----------------------------------------------------------------------------------------------------------------
Benin...................................................... 4,065,408 1,263 3 2.45
Botswana................................................... 2,436,232 356 7 36
Cameroon................................................... 10,378,900 3,280 3 8
Ghana...................................................... 9,901,068 4,424 2 3.6
Kenya...................................................... 42,391,034 6,666 6 14
Senegal.................................................... 5,513,517 2,091 3 1
South Africa............................................... 76,284,892 11,645 7 20
Tanzania................................................... 27,217,215 7,603 4 16
Uganda..................................................... 16,702,846 4,740 4 6
Zambia..................................................... 12,131,695 2,280 5 20
Zimbabwe................................................... 29,149,405 2,826 10 25
----------------------------------------------------------------------------------------------------------------
I am not saying that the two are causally connected, only that we
probably need to be thinking of interventions in addition to condom
social marketing, since we do not yet see national-level results in
Africa. And I say this as someone who has worked in condom social
marketing. Meanwhile, evidence is accumulating that reduction in
numbers of sexual partners, which can result from abstinence and
fidelity interventions, can reduce national HIV prevalence levels.
So this is not to argue against a continuing role for condoms.
Rather it is to argue that the US should put some real efforts and
resources into promoting balanced ABC programs, especially in
generalized epidemics. Condoms in fact seem to have played a
significant role in impacting national HIV infection rates in countries
like Thailand, where infection are concentrated in high-risk groups.
Yet even in Thailand, there was a significant decline in premarital and
extramarital sex in the general male population shortly before
Thailand's prevalence decline of the mid-1990s.
In sum, AIDS prevention works when done in the right way. I hope a
substantial proportion of the new funds for AIDS will be allocated to
effective prevention programs.
References:
Hearst, N., and S. Chen. (2003). Condoms for AIDS Prevention In The
Developing World: a Review Of The Scientific Literature. Geneva:
UNAIDS.
USAID (2002). The ``ABCs'' of HIV prevention: Report of a USAID
technical meeting on behavior change approaches to primary prevention
of HIV/AIDS. Washington, D.C.: ``ABC'' Experts Technical Meeting,
September 17, 2002.
Mr. Bilirakis. Without objection. Thank you very much, Dr.
Green. Thanks to all of you.
My emphasis on coordination efforts, I would ask you all to
submit to us, this is your opportunity to be king, as we say,
in other words, if I had my way type of thing, what you would
do. In writing, advise on changes you think should be made and
how things should take place, not only in coordination, but in
general. We're an ivory tower here and my colleagues, I
consider myself an exception. My colleagues are probably the
most intelligent, hardest working people I've ever seen. There
are exceptions to that too. But we don't----
Mr. Brown. Mr. Chairman, you have some people in the back
of the room from your District and I just want to tell them
that you are one of the best Members of Congress.
Mr. Bilirakis. Quid pro quo, also up here, so he's got to
expect a quid pro quo for the thank you, Mr. Brown.
But anyhow, let us know in writing, tell us what you think
should be done. Some things are within the purview of the
Congress, some things are within the purview of HHS, CDC,
USAID, etcetera, etcetera. We can be influential as far as
those areas are concerned. It may not just be legislation.
So I would appreciate that, the committee, I know would
appreciate it. Mr. Brown would. As I said before, you are the
troops. You are the firing line. You know these things.
Ms. Monico, the ABC program, the ABC concept was one that
your country decided upon, is that right?
Ms. Monico. Yes sir.
Mr. Bilirakis. It was not imposed upon you by the United
States or any of the organizations?
Ms. Monico. I think it was a concerted effort. When we
started implementing programs in Uganda, we worked very closely
with global AIDS participants and WHO, so it was a program that
we discussed with WHO, but in implementing it it relied a lot
on the Ugandan culture, on the community.
Mr. Bilirakis. And I think you all have testified to the
success in Uganda. I'm not sure that Ms. Barry agrees how
attributable it is to the ABC concept, but I think the rest of
you, I don't know about Mr. Smith, I'm not sure he addressed
it. I think he does too.
So we have a program which is working in Uganda. And we all
agree that that may not work in every locale and we've said
that right at the outset.
What role, Dr. Green, if you know, have faith-based groups
and organized religion played in the success of the ABC program
in Uganda and what role do you believe they should play in the
United States global AIDS research.
Mr. Edward Green. Well, the faith-based organizations were
involved in Uganda in AIDS prevention from the very beginning
and when the first bilateral USAID program began, I think it
was 1991, there were three major faith-based organizations.
They were given subgrants through the USAID contractor and were
involved in prevention and they--the FBOs, the faith-based
organizations were particularly adept at--you might say they
have a comparative advantage in promoting abstinence and
faithfulness because this is what--and the three faith-based
organizations, groups were Anglican, Catholic and Muslim and we
have evaluation research showing that there was--that these
organizations reached a lot of people at the grass roots level
and there was measurable behavioral change. In fact, I could
even cite some statistics of behavioral change that's of
greater magnitude than what we have in the charts and it's in
my testimony.
Mr. Bilirakis. So you would say that the ABC concept should
continue to play a role in every instance or virtually every
instance?
Mr. Edward Green. In Uganda or generally?
Mr. Bilirakis. Generally.
Mr. Edward Green. In general, I'd say that the ABC approach
as it was implemented in Uganda, we have two basic types of
epidemic patterns, concentrated and generalized and in Sub-
Saharan Africa and the Caribbean we have generalized epidemics
where HIV infection is found in the general population and I
think the ABC approach is probably, at least the way it was
implemented in Uganda is especially appropriate for Africa and
the Caribbean, not that it wouldn't work elsewhere.
Mr. Bilirakis. We can spend a lot of time on that
particular subject, but in the interest of time here, I'm not
going to go any further. I'm going to yield to Mr. Brown.
Mr. Brown. Thank you, Mr. Chairman. Mr. Smith, first thank
you for your testimony and for your comments when we were
talking in the front row before the testimony about
tuberculosis and your support for what Ms. Wilson and I and Mr.
Green and others are trying to do.
I don't disagree that abstinence has a place in reducing
the rate of HIV/AIDS. I think that's pretty clear. And I
certainly don't question what's worked in Uganda. I think
you've all spoken and especially Ms. Monico, very articulately
and passionately about that.
But I'm not at all convinced that a program that works in
one country automatically works in another. I'd like you just
to comment on the role, if you would, of abstinence and what's
happened in Sierra Leone in terms of rape, in terms of the
cases of young girls and Zimbabwe also who desperately want to
go to school but can't afford school fees, exchange sex for
money in order to go to school and there are cases of young
girls and women who are starving and get food for themselves
and their families in exchange for sex. I mean if you would
respond to using ABC as a model when societies also have to
deal with problems like that.
Mr. Smith. Right. I think actually it's one of the
advantages of ABC because it is compartmentalized and they can
target where appropriate the use of barrier protection. It's in
respect to broad populations when Dr. Green was talking about a
generalized epidemic that abstinence and be faithful has their
power, abstinence equates to a delay of sexual debut; be
faithful equates to a reduction in the numbers of partners. And
it's numbers of partners that fuel these STDs.
Regarding more of the exception and that's the case you're
talking about where the sex trade or prostitution, the
instances where young women, particularly, will sell sex to
survive, that's where you can have people who are very good at
reaching these highly defined communities and target condoms,
but on a broad scale, it's a different issue than what we're
used to here when we talk about comprehensive sex. We think of
talking about all these things together and that's really not
what we saw when we were in Uganda.
I do know, I want to add one thing. Having gone to
Mozambique, South Africa, Botswana where the prevalent message
that we have funded and given is condoms, you know, it's not
working. So we need to rethink our strategy and I'm not saying
we need to impose ABC, but we really need to look at what has
worked as well as what hasn't worked.
Mr. Brown. I don't know that those are always exceptions,
some of the things we both talked about, but I accept that. I
think you had said in your testimony Uganda has done it their
way. Other nations have done it our way. That's part of the
point of why here the President's plan will go too much into a
one size fits all, it's worked here, let's do it elsewhere.
That to me is the attractiveness of the Global Fund. The Global
Fund will in a sense contract with Bangladesh, with India, with
Brazil, with Mexico, with Eritrea and work their programs
through their NGO's or their--or any NGO that's endemic to that
country and their health ministries, whatever.
Ms. Barry, I'd like to talk to you for a second about
Russia. I'd like to ask you if ABC would work in Russia. Ms.
Barry, just for disclosure reasons, is a friend of mine who,
with whom I traveled to Siberia and to Moscow with last summer,
who speaks fluent Russian, who is a nurse and who has seen this
increase in Russia in TB and especially in--beginning in HIV.
Two questions for you. One, would ABC work in Russia and
second, what would the Global Fund mean to Russia versus what
you've seen with bilateral, particularly USAID activities in
Moscow and both in European and Asia and Russia?
Ms. Barry. As regards to the first question, would ABC work
in Russia? The way that the epidemic is spreading in Russia and
not just Russia, the entire former Soviet Union, no. Ninety-
five percent of the cases of HIV right now that are being
spread through IV drug use in Russia, so unfortunately, ABC
would not help contain the epidemic in these countries and I
just want to reiterate which has already been said today, but
Ukraine and Russia right now have the fastest rising HIV rates
in the world. And we're at probably 2 million cases in Russia
right now. If we don't start containing it, we'll be close to
10 million in a few short years.
Mr. Bilirakis. And that is due principally to drug use?
Ms. Barry. Yes. And we're starting to see the transmission
in the heterosexual population as well and in that case,
perhaps messages, the ABC message would help in some cases, but
I think as I've said in my statement and as Chairman Bilirakis
has pointed out, I don't think that we really can pinpoint that
the ABC methodology is what has brought the transmission down
in Uganda, but that's a different part.
Second part of the question, how the Global Fund would
help----
Mr. Brown. If I could interject one thing. As Ms. Barry
talked about the fastest rising HIV/AIDS rates in the world are
in Russia and Ukraine, those are also two countries with very,
very high multi-drug resistant TB and that's why Russia and
Ukraine and India probably are the next real basket cases in
the world that are going to be just devastated by these
diseases. I'm sorry.
Ms. Barry. Thank you for pointing that out and I just wish
to say that I was here actually in Washington last week on the
Hill and at the State Department and at USAID with three
colleagues from Russia trying to talk about that very issue,
that we have never seen rates of MDR-TB like we're seeing in
Russia today and once HIV and MDR-TB hit there, we really don't
know what to expect because we've never seen anything like it
before.
As to USAID assistance in Russia, I had a pretty frank
conversation with the State Department last week about what I
thought of the programs that have been implemented there. I
really think, unfortunately that we've frittered away millions
and millions of dollars in health care in Russia on some
programs that have really shown very little impact there.
To my knowledge, and we are not a USAID recipient so I
don't know the inner workings of all the programs, but to my
knowledge they've funded very, very little treatment of
tuberculosis in Russia and where they have funded it, it has
been clearly through other agencies, CDC being one of them. So
I think that a Global Fund approach to Russia that would be
based on an application that the Russians develop themselves
would actually be a much more effective use of our money.
Mr. Brown. Last follow-up real quick, Mr. Chairman, would
that be mostly--would the Global Fund application--Russian
applications to Global Fund would they be mostly NGO's or would
they be mostly health ministries or obelisk ministries of
health or regional kinds of governments?
Ms. Barry. It depends on which disease you're talking
about. I think if we're talking about tuberculosis, it would be
much more ministerial, let alone on a local government level.
If we're talking about HIV, the NGO's there in Russia have
shown really good activity and positive activity in prevention
activities, but if we're going to be talking about treatment, I
would definitely also be through government entities.
Mr. Brown. Thank you.
Mr. Bilirakis. Ms. DeGette?
Ms. DeGette. Thank you, Mr. Chairman. Ms.
Mukasa-Monico, I want to congratulate your country for the
work they've done and I just have a couple of questions to ask
you about how the ABC program has worked.
The first question is do you think the program would have
been successful if you eliminated the C from the program or if
you very tightly limited condom education say to bars and
prostitutes?
Ms. Monico. My quick response would be no, it would not. It
takes a comprehensive package of prevention interventions to
make it work. And when I hear the Russian story, I think if we
talk about sexually transmissional HIV, there is no doubt that
it has to be ABC.
Ms. DeGette. Let me ask you because I found your testimony
intriguing that the faith-based organizations in your country
were very effective at the A and B and then the condom
education came in too. I'm wondering how that was structured,
how Uganda structured both bringing in faith-based operations
to talk about abstinence and about few partners and then how
that worked with the condoms. Because I assume the faith-based
organizations, most of them did not do the condom education.
Ms. Monico. You're right. I'll give you an analogy of how
we approached it. What we all realized was that it was
impossible to change a 2,000 year legacy of what is happening
over 17 years, so there was no way we wanted the charge to
change their creed that actually you can abstain and you can be
faithful and avoid HIV because you can, but at the same time,
the charge realized that they cannot go on living in denial
about the reality that the context in which we live actually
demands that people protect themselves more than just being
abstinent and being faithful.
So whereas they did not actually promote condoms, they
would refer people to where they can get information about
condoms and the condoms themselves. If you go back to what they
are talking about, you would be shocked to find that they
actually accept condom use within a family setting. You can use
a condom if you are married. Just by the mere fact that they
accept the use of a condom in a marriage, that shows that they
also understand the context in which they are working with and
the fact that having extramarital relationships is very
possible and getting infected even higher.
Ms. DeGette. Dr. Green, do you think that the condom is an
important component of the ABC program in Uganda?
Mr. Edward Green. Yes, I do and just to respond to your
last question, the faith-based organizations at the outset said
that they would promote the A and the B of the ABC. They didn't
want to be forced to promote condoms and so there was at least
with the USAID funding there was an agreement that they could
do that, but USAID asked that the faith-based organizations not
criticize condom use.
What all three faith-based organizations found when they
got into AIDS prevention is that there were some people who
were already infected or some who wouldn't change their
behavior and they quietly promoted condoms to them.
Ms. DeGette. And Mr. Smith, I know in your testimony, in
your summary points, you say that we should allow faith-based
organizations to promote only A and B, without the threat of
coercion to promote C and being an old civil libertarian I
happen to agree that I don't think we should ever force a
faith-based organization to promote something, but on the other
hand, if we're spending Federal dollars to put AIDS programs
like the ABC program in operation in other countries, I'm
wondering what you think of all this. Do you think faith-based
organizations should be able to just get Federal funding to do
a slight component of it or how is that all going to work in
your view.
Mr. Smith. Sure and you can ask it the other way. If there
are people who are really good at C, promoting C and targeting
C, should they be able to get money just for that or do they
also have to promote abstinence and be faithful.
Ms. DeGette. That's an excellent question. If you'd answer
my first question.
Mr. Smith. I'll be happy to.
Ms. DeGette. Then maybe we can get to that.
Mr. Smith. I think that groups that are good at what
they're good at and are known for ought to be allowed to do
just that.
Ms. DeGette. See the problem I have is if what these folks
are--I mean what virtually everyone is saying is the ABC
program works, so my question is how is it going to work,
especially if we're not doing it in a multilateral context to
give money to someone just to do A and B?
Mr. Smith. You've got 600 different AIDS groups in Uganda
right now. Some are good at one aspect of this and some are
good at another and they aren't all doing the same thing. The
problem that you have in many of these countries, we just have
people in our office from Nigeria, they can't get funding
unless they say they're also going to promote condoms. Why do
we put that kind of restriction on them if they aren't good at
it and don't want to do it? Why should we make someone promote
abstinence if they aren't good at it and don't want to do it.
Ms. DeGette. Thank you. Thank you, Mr. Smith.
Mr. Bilirakis. A good trial lawyer there. She knows when to
quit.
Ms. Barry, as I understand it, the Global Fund would not
approve your project in Haiti in the first try, is that right?
Ms. Barry. No sir, they were approved in the first round.
Mr. Bilirakis. They were approved in the first round? Okay.
Well, I wanted you not to explain verbally, but in writing why
because I wanted to know maybe what kind of problems might
exist there.
All right, so it was approved in the first round. That
being the case, I'm just going to ask all four of you to first
of all, I've already asked all of you to further show us in
writing in your own words suggestions, ideas and things of that
nature that we might take into consideration here to and to
maybe use them in this battle in this fight. But additionally,
your willingness to respond to any questions that we might have
of you as time goes on in writing and hopefully respond to them
in a prompt manner.
Having said that, I want to again thank you on behalf of
Mr. Brown, myself and all of the subcommittee and thank you,
particularly for your patience and your understanding as a
result of the delays we had this morning.
Thank you very much.
[Whereupon, at 1:55 p.m., the hearing was concluded.]
[Additional material submitted for the record follows:]
The Alan Guttmacher Institute
March 20, 2003
The Honorable W.J. ``Billy'' Tauzin, Chairman
Committee on Energy and Commerce
House of Representatives
2125 Rayburn House Office Building
Washington, DC 20515
Dear Mr. Chairman, on behalf of The Alan Guttmacher Institute
(AGI), a not-for-profit corporation that conducts research, policy
analysis and public education on matters related to sexual and
reproductive health, I appreciate the opportunity to submit written
testimony for the official record of the March 20, 2003 full committee
hearing on global HIV/AIDS programs, and specifically on the importance
of maintaining a comprehensive approach to HIV/AIDS prevention.
Uganda's experience with sharply declining HIV prevalence rates in
the 1990s has drawn worldwide attention as public health experts seek
to understand what accounted for Uganda's success and whether that
success can be replicated elsewhere. There is both much information and
much misinformation about 1) what behavior changes took place in that
country during the period and 2) the nature of the government HIV
prevention program that was, and is, in place there.
With regard to behavior changes, a detailed analysis conducted by
AGI in 2002 found that reductions in the risk of exposure to HIV in
Uganda during the 1990s resulted from all three of the following
behaviors: delayed sexual initiation among young people (increased
abstinence), reductions in the number of individuals' sexual partners
(increased monogamy) and safer sex practices (increased condom use
among people engaging in sexual intercourse). Indeed, increased
abstinence by itself may have made the smallest contribution to reduced
HIV prevalence; condom use and reductions in the number of people's
sexual partners both increased substantially more than did the
proportion of young people abstaining from sex.
With regard to the nature of the Ugandan government's HIV
prevention program, it is worth remembering that to whatever extent
that program (among the myriad other societal factors also at play
during the period) was responsible for the observed behavior changes,
including the increase in abstinence, the program was an ``ABC''
program (``abstinence, be faithful, and use condoms''), which employed
a comprehensive, not an ``abstinence-only'' approach.
I am submitting a copy of AGI's detailed analysis ``The Role of
Behavior Change in the Decline of HIV Prevalence in Uganda,'' (http://
www.guttmacher.org/media/uganda__memo02.pdf ) along with an article
from AGI's The Guttmacher Report on Public Policy entitled ``Flexible
but Comprehensive: Developing Country HIV Prevention Efforts Show
Promise,'' (http://www.guttmacher.org/pubs/journals/gr
050401.html), which places the data in a policy context.
In conclusion, Mr. Chairman, there is nothing in the Uganda
experience that justifies an ``abstinence-only'' approach to HIV
prevention, nor is there reason to believe that such an approach would
be any more successful than a ``condom-only'' approach would be.
Rather, common sense and responsible public health practice would
dictate an approach that ensures people's access to full and accurate
information on all the ways to reduce exposure to HIV, one that at a
minimum, does not disparage any of the available HIV prevention
strategies in its zeal to promote another.
Sincerely yours,
Cory L. Richards, Senior Vice President
Vice President for Public Policy
______
Global Health Coucil
April 23, 2003
The Honorable Michael Bilirakis
Chairman, Subcommittee on Health
Committee on Energy and Commerce
US House of Representatives
Washington, DC 20515
Dear Mr. Chairman; Thank you very much for the opportunity to
elaborate further on my testimony before your Subcommittee. At this
critical time in the development of the US government response to the
global AIDS pandemic, I am pleased to offer my views on how the US
government could expand its support for programs that seek to halt the
spread of the global AIDS pandemic.
the need for a comprehensive approach to the global aids pandemic
The Global Health Council supports the critical evidence-based
strategies that have worked in Uganda and Thailand, and have been
endorsed in USAID documents,1 by UNAIDS, WHO and other
organizations 2. These strategies are comprehensive and
recognize the synergism between prevention and care and support. They
go well beyond the currently popular ``ABC'' approach--``abstain, be
faithful, and use condoms.'' While these three elements are clearly
important, the evidence base supports the need for much broader
prevention efforts accompanied by caring for those already affected
with dignity and compassion. Treatment and prevention of opportunistic
infections extend the healthy lives of persons living with HIV and
AIDS, increase their economic and social productivity and allow PLWHA
to participate more fully in prevention efforts. As rapidly as
treatment can become more widely available, voluntary counseling and
testing will become less stigmatized, more widely used and more
meaningful as a prevention strategy. Furthermore, antiretroviral
therapy is expected to reduce viral load, which will decrease the
likelihood of transmission and slow the epidemic.
---------------------------------------------------------------------------
\1\ e.g., Lamptey, P. Zeitz, P and Larivee, C, (eds,) Strategies
for an Expanded and Comprehensive Response to a National HIV/AIDS
Epidemic, A Handbook for Designing and Implementing HIV/AIDS programs,
Family Health International, 2001.
\2\ Op cit. 1
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The ABC approach fails to recognize that marriage, rather than
being a protective state, is in itself the most significant HIV risk
factor for many women 3. Most would agree that married women
are not free to abstain from sex. HIV is spreading most rapidly among
adolescent girls ages 15-19 and abstinence-only programs offer no
alternative for the majority of sexually active adolescent women in
developing countries who are already married.4
---------------------------------------------------------------------------
\3\ S. Clark, Early Marriage and HIV Risks in Sub-Saharan Africa,
University of Chicago, 2003 draft report cited with permission
\4\ UNAIDS, 2002.
---------------------------------------------------------------------------
The ABC approach focuses entirely on changing the behavior of
individuals. Behavior change strategies must be supported by policies
and programs that protect individuals from non-sexual transmission.
These include:
condom availability, including attention to universal access
and cost;
prevention of mother to child transmission (MTCT);
sexually transmitted disease management and treatment,
including adequate drug supply;
voluntary counseling and testing (VCT) practices that assure
privacy and confidentiality, which lead to early diagnosis of
HIV infection and act as an entry point for prevention programs
based on behavior change and prompt individuals to seek care;
blood safety; and
safe injection and harm reduction for IV drug users.
Prevention and treatment serve overlapping but not identical goals.
For this reason no nation's health policy strictly enforces trade offs
between prevention and care. Prevention and care efforts are not simply
additive as each strategy increases the impact on the other through
synergistic effects. Outcomes are therefore, not linear. Further,
prevention and treatment involve different sectors and constituencies.
It is therefore advisable to invest in both simultaneously to achieve
more than would be accomplished by investing in either alone.
We also recommend that when allocating funds for prevention
efforts, Congress encourage strategic planning, decentralization and
autonomy to allow local development and implementation of culturally
appropriate and equitable programs and services. Imposing restrictions
on funds is contrary to the principles of ownership and political
engagement that are necessary to successful prevention efforts.
Care and treatment programs must include the prevention and
treatment of sexually transmitted infections and opportunistic
infections as well as treatment with anti-retrovirals. But, these
prevention, care and treatment programs will not be enough alone to
halt the pandemic. We must also provide funding to support the
development of support systems for those infected and affected by the
HIV/AIDS pandemic to ensure on-going systemic assistance after one has
been diagnosed as positive. This support system should include:
psychosocial support;
on-going issue specific counseling;
programs that provide education about HIV/AIDS in order to
address stigma and discrimination issues; and
social welfare support for the affected families.
further discussion of the success in uganda
I would like to expand upon my testimony and talk about my personal
impressions of what worked in Uganda. Success was achieved in Uganda
because there was strong leadership from the President. But, strong
support from the President was not enough--he worked very closely and
diligently with the resilient citizenry of Uganda as a whole. We were
openly cognizant of the enormous fatal danger that we were confronting
and regardless of who we were--we acknowledged that we must work
together to address this risk. We adopted new strategies that had never
been tried before and we tried to creatively develop programs that
would fit our culture and situation. Over time, it was determined that
some strategies were appropriate while others were found not to work
and we did not continue them. But, most importantly, the community
developed and owned the process of building a strong prevention, care
and treatment program. Early in the process, we realized that we needed
outside donor support for these activities and countries, such as the
United States joined our efforts. Most importantly, they built capacity
within the country to support the effort but they did not run the
programs for us.
Uganda like all other countries with HIV infections is implementing
a comprehensive package of services. Overall, strategies in Uganda
5 were implemented in the context of:
---------------------------------------------------------------------------
\5\ Hogle, J., (ed) What Happened in Uganda, Declining HIV
prevalence, behavior change and the National Response, USAID, 2002.
strong political will and leadership, emphasizing a ``matter-
of-fact'' approach to condom use and VCT, and constant media
attention to these issues;
the involvement of government and other stakeholders from
outside government including community organizations and
business in a social mobilization movement;
open and candid discussion of HIV and AIDS, sexual behavior
and personal risk;
relevant and sensitive transformation of values and behavior
change that emphasized not judging or stigmatizing those living
with AIDS;
strong educational programs for in and out-of-school youth and
adults promoting AIDS awareness and safe sexual practices as
``patriotic duty;''
broad decentralization and community mobilization involving
and caring for persons living with HIV and AIDS;
strong emphasis on the empowerment of women and girls to
engage in decision-making and policy formation;
comprehensive counseling to reinforce prevention strategies
for those who tested negative as well as those who are
positive; ``post-test clubs'' provide long term support for
sustained behavior change;
reduction in the number of non-regular partners and
significantly increased condom use with non-regular partners
and among high risk groups; and
use of innovative behavior change strategies including drama,
music, and involvement of popular public figures to demystify
the disease and reduce stigma and discrimination against HIV
positive persons.
Our experience in Uganda strongly suggests that successful
prevention efforts are based on comprehensive behavior change
strategies that address stigma, promote open dialogue and accurate
assessment of personal risk. These should be led and supported by high
level political commitment and diverse community participation in
prevention and care and support efforts. Mother to child prevention
programs were critical to our success but it must be recognized that
even with confidential testing and treatment, women fail to access this
safe and effective treatment due to stigma and fear of exposing their
HIV status to a partner. Providers were forced to implement this
program in a sensitive manner as they anticipate that women may face
personal risk of violence and ostracism when their HIV positive status
is determined and providers must deal with these risks in a sensitive
and protective manner.
Unlike the experience of Uganda, most countries have not been able
to attain the ideal HIV/AIDS response because of discrimination,
stigmatization of high-risk groups and denial by the community that
there is a problem. In addition, the access to support services is
limited and systems are not in place to support voluntary counseling
and testing programs, which are the entry point for behavior change
programs as well as services that provide care and treatment. Finally,
budgetary constraints have led countries to make the hard choice
between investment in prevention interventions and care and support,
especially ARVs.
ADDITIONAL RESOURCES REQUIRED
There is wide global recognition that AIDS spending in low and
middle income countries needs to increase. We are very encouraged by
President Bush's call for $15 billion over the next five years and look
forward to working with Congress and the Administration to make this
pledge a reality. Other studies have examined this issue more
specifically and have found that in order to contain and ultimately
reverse the broadening HIV pandemic, efforts must be expanded as
quickly as possible. A recent mathematical modeling exercise jointly
published by UNAIDS, WHO and the CDC 6 illustrates the
impact of scaling up prevention, care and support efforts, and
contrasts the effect of doing so earlier as opposed to later. With
global expansion of the strategies that led to the successes achieved
in Uganda and Thailand, 29 million new HIV infections could be averted
by 2010. A delay of three years in full implementation of these
strategies will reduce this number by half. Fifteen million lives hang
in the balance between an ambitious but feasible program to assault the
virus and a delayed response.
---------------------------------------------------------------------------
\6\ Stover, J, Walker, N, Garnett, GP, Salomon, JA, Steneck, K,
Dhys, P, Crassly, N, Anderson RM, and Schwartlander, B. Can we reverse
the HIV/AIDS pandemic with an expanded response? The Lancet, 2002: 360:
73-77.
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The key to a successful US government program to address the global
AIDS pandemic is that it must be comprehensive. Just like combination
therapy has been proven to be the solution to HIV treatment, so too
combination prevention is the key to stopping the spread of HIV. There
is no one size fits all solution. The US government was one of the
first industrialized countries to recognize the scope of this pandemic
and responded effectively. It is critical that we continue these
efforts by empowering communities to determine the most culturally
appropriate solutions for themselves.
Thank you again for this opportunity to expand upon my testimony
and I am happy to answer any additional questions at your convenience.
Sincerely,
Sophia Mukasa Monico, Senior AIDS Program Officer
Global Health Council
______
Institute for Youth Development
April 14, 2003
The Honorable Michael Bilirakis
Chairman, Subcommittee on Health
Committee on Energy and Commerce
U.S. House of Representatives
2125 Rayburn House Office Building
Washington, DC 20151
Dear Chairman Bilirakis, in response to your letter requesting what
we feel are key elements of a successful HIV prevention model, I will
be brief and to the point. The biggest predictor of a sexually
transmitted disease is number of lifetime partners. The greatest
influence on that is age of sexual debut. The younger an individual has
sexual relations, the more likely they are to have a large number of
lifetime partners. Delaying sexual debut becomes of primary importance
to any prevention campaign.
This means the promotion of abstinence. It should be promoted in a
way that says it is the only way to avoid risk, and there should not be
an option for risk reduction for young people. We offer no options for
reduction with alcohol, drugs, tobacco, and violence for youth. The
message is unequivocal, ``do not participate in this behavior.'' We
need to be consistent with sexual activity as well.
In respect to limiting partners, the second message as seen in the
Uganda ABC model is ``be faithful.'' We must let people know that the
more partners they have the more risk they entail. The goal for
everyone should be one lifetime sexual partner, period. Lastly, we
should discontinue any broad social marketing of condoms. There is no
instance in any country we have studied where the broad social
marketing of condoms has reduced infection rates. If anything, there
seems to be a correlation with increased infection rates with increased
broad social marketing of condoms.
We need to be very targeted in any promotion of a risk reduction or
harm reduction message. People in discordant relationships where one is
positive and one is negative, should not first be offered condoms. They
should first be offered the opportunity not to infect the other
individual by avoiding intimate sexual activity where body fluids are
exchanged. Condoms should be the last resort not a first offer in these
circumstances. Targeting those who have multiple partners with condoms
may make a small difference in an HIV epidemic, but we need to
recognize that they should be targeted to very limited high-risk
populations.
In respect to disbursing funds, the United States has an incredible
infrastructure in all the countries we visited in Africa to adequately
distribute both treatment and prevention dollars. We have not been
impressed by some of the maneuverings regarding the Global Fund. We
should continue to give resources to the Global Fund, but with the
condition that it prove itself effective before we give any increases
at all. The United States needs to direct the President's international
effort, and if done properly we can make a significant difference in
the world, and ultimately will receive recognition for doing so.
Lastly, we have visited those parts of Africa that have promoted
condoms broadly. They have increasing HIV infection rates. We have also
visited Uganda that has a declining HIV infection rate, which heavily
promotes ``Abstinence'' and ``Be Faithful.'' In one area young people
all too frequently will have dramatically shortened lives, and in the
other there is increasing hope among youth for brighter futures. The
differences are striking. We need to take note and we need to take
action.
Thank you, again, for the opportunity to testify before your
committee, and to respond to your questions.
Sincerely,
Shepherd Smith
President
______
Partners in Health
April 3, 2003
Mr. Michael Bilirakis, Chairman
Subcommittee on Health
Committee on Energy and Commerce
2269 Rayburn House Office Building
U.S. House of Representatives
Washington D.C., 20515-6115
Dear Chairman Bilirakis, Thank you for the opportunity to testify
before the Subcommittee on Health on March 20 during the hearing on
HIV/AIDS, TB and Malaria: Combating a Global Pandemic. I very much
appreciated the chance to present our views on how best to allocate the
funds for the new initiative. Per your request, please find below
written recommendations based on my testimony and on some issues that
were raised during the hearing, to which there was no time to respond
orally. These views reflect the position of Partners In Health, the
organization for which I work, based on our deep commitment to
providing health services to persons living in resource-poor settings.
At least 1 billion dollars should be allocated to the Global
Fund to Fight AIDS, TB and Malaria (GFATM). The GFATM is the
only organization in the world with the ability to fund the
large-scale prevention and treatment programs which are
currently needed. These programs should include both non-
governmental organizations and government entities, as the
extensive networks that are needed to reach all persons at-risk
or already infected with these diseases can only be expanded
through both private and public facilities.
We must address HIV and TB in those countries with the highest
HIV and TB rates, included in the fourteen countries mentioned
in the President's initiative. However, we must not neglect
those countries where the next epicenter of TB and HIV will be,
including Russia, India and China. If we do, in 5-10 years they
will find themselves with infection levels similar to those
currently seen in the highest-burden countries.
As I mentioned during my testimony, the U.S. Centers for
Disease Control and Prevention (CDC) have extensive national
and international experience in preventing and treating HIV/
AIDS, TB and Malaria. The Committee should directly fund the
CDC for their international work in TB, rather than channeling
the money through the U.S. Agency for International Development
(USAID) which adds an extra layer of bureaucracy, thus
decreasing the amount of funds available for implementation of
actual projects. In addition, USAID projects have not made much
progress in controlling any of these diseases over the past 20
years; in this time of limited resources, we must find the most
efficacious means for treating and preventing these diseases.
During the hearing we had very little time to respond to the
other presenters' testimonies and I would like to share PIH's
views on the Uganda experience.
First, while there is no question that Uganda has achieved
success in decreasing the prevalence of HIV/AIDS,
unfortunately, the statistics that were presented in the
charts and written testimony of Dr. Green and Mr. Smith do
not show a decrease country-wide (they only show data from
9 urban sights, while 87% of the population live in rural
areas). In addition, the 9 sights were antenatal clinics
which do not reflect the prevalence in the wider
population. In fact, data from antenatal clinics can be
very biased and not indicative of the status of the rest of
the population.
Second, a decrease in prevalence which was shown in the
charts does not necessarily reflect a decrease in incidence
(new cases). As other African countries are not showing
such declines, Uganda must be doing something correct, but
the data presented does not explain what that is. This
leads to my final point;
As I alluded to during my comments, I am very concerned
about expanding the ABC model too widely in other
countries. The success of the Ugandan experience cannot be
attributed to one factor. There were several factors at
play during the decrease in Ugandan prevalence rates,
including strong government commitment, large amounts of
foreign aid, raising the status of women, relative
political stability, extensive private and public networks
involved in prevention efforts, and all three parts of the
ABC model. To date, no data has been presented that shows
that any one of these factors was more important than the
others.
The ABC model will have little impact in countries where the
HIV/AIDS epidemic is being spread through intravenous drug use,
such as many countries of the former Soviet Union where HIV/
AIDS infection is rising faster than anywhere else in the
world.
During Mr. Allen's testimony and the question/answer session
with him, he avoided directly answering how the 2 billion
dollars President Bush promised for treatment would be used. He
vaguely responded that much of the funding would be channeled
through antenatal clinics in the fourteen countries. I am very
concerned with this lack of clarity and the suggestion, that by
treatment, the Administration will only be spending the funds
on preventing maternal-child transmission, rather than
beginning life-long treatment for men and non-pregnant women.
If the Administration is allowed to substitute preventing
transmission to infants, a laudable goal in and of itself, but
a very narrow definition of treatment, in an age where 40
million persons are infected with the disease, this would be a
serious misuse of funds. I respectfully request that this issue
be pursued more intensively by your Subcommittee.
Finally, we can no longer approach these complicated diseases
with simple, one-step solutions. Each disease requires
developing the health infrastructure and training local health
professionals, as well as providing adequate funding for both
prevention and treatment. Once these infrastructures have been
strengthened, they will be able to provide services for other
serious health problems that many of the countries are facing.
Thank you once again for allowing me to testify and provide you
with written recommendations. Please contact me for further
clarification.
Sincerely,
Donna J. Barry, N.P. M.P.H., Russia Project Director
Partners In Health Program in Infectious Disease
and Social Change, Harvard Medical School
cc: Ranking Member Sherrod Brown
______
April 2, 2003
Michael Bilirakis
Subcommittee on Health
2125 Rayburn bldg.
Washington DC 20515
Dear Chairman Bilirakis: Thank you for the opportunity to testify
before the Health Sub-committee on March 20. I'm writing in response to
your request that those who testified write to you with some
suggestions about how the President's Initiative can have the most
impact in combating AIDS.
My comments are limited to AIDS prevention rather than treatment.
We will save many more lives through prevention than through high-cost
programs of treating those already infected.
As I showed in my example of Uganda-and many others agreed with my
assessment, including at least one congresswoman-the integrated ABC
approach seems to be a good model for combating AIDS in ``generalized''
epidemics. Another person who testified objected that the ABC approach
would have little impact in Russia. This is true, since Russia's
epidemic is almost entirely driven by injection drug use. But this is a
red herring. The new money for AIDS is going to the generalized
epidemics of Africa and the Caribbean, and not to the ``concentrated''
epidemics of Russia or Ukraine. There is every reason to believe that
the ABC approach is suitable for the countries where the new money is
in fact going. We see ABC interventions as well as stabilization or
reduction of national HIV prevalence not only in Uganda but also in
Senegal, Jamaica, and the Dominican Republic, as well as in certain
populations in Zambia and Ethiopia.
There is a new global policy at USAID called the ABC policy. To
ensure that this policy is implemented, it may be useful or necessary
to have some oversight over funds allocated to AIDS prevention. I'm not
sure how the CDC sees the new ABC policy. Nor am I sure where the
oversight should be coordinated, or exactly who should do it. All I am
certain of is that business-as-usual AIDS prevention has had little
impact to date, especially in the areas targeted by the president's
initiative. Therefore we need to do prevention differently.
I am more than willing to discuss this matter with you or anyone
else on your committee or sub-committee, at any time. I would be happy
to provide more evidence as well.
Sincerely yours,
Edward C Green, PhD, Senior Research Scientist
Harvard Center for Population and Development Studies
______
Human Rights Watch
March 27, 2003
The Honorable W.J. ``Billy'' Tauzin, Chairman
Committee on Energy and Commerce
House of Representatives
2125 Rayburn House Office Building
Washington, D.C. 20515
Dear Mr. Chairman, I write on behalf of the HIV/AIDS and Human
Rights Program of Human Rights Watch to submit testimony for the
official record of the March 20, 2003 hearing of the Subcommittee on
Health of the Committee on Energy and Commerce, ``HIV/AIDS, TB, and
Malaria: Combating a Global Pandemic.''
Human Rights Watch writes to caution that any failure to provide
complete and accurate information about HIV/AIDS prevention to young
people, including information about condom use to prevent HIV
transmission, violates their rights to information and to the highest
attainable standard of health, and may have fatal consequences for
them. We would like to emphasize as well that addressing inequalities
that put women and girls at added risk of infection from HIV/AIDS must
also be an important part of U.S.-funded prevention efforts.
protecting the right to information about hiv/aids prevention
According to a U.N. study released last July, most of the world's
young people have ``no idea how HIV/AIDS is transmitted or how to
protect themselves from the disease.'' 1 A recent study of
HIV/AIDS education in schools suggests an explanation for such
widespread ignorance: many teachers censor information they provide
about HIV prevention, omitting information about the role of sex in HIV
transmission and about condoms as a means to prevent transmission.
2 In combating HIV/AIDS in the United States and abroad, the
U.S. government should make sure that U.S.-funded HIV/AIDS prevention
efforts protect the right of all people to the knowledge as well as the
skills and services necessary to protect themselves from HIV.
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\1\ UNICEF, UNAIDS & World Health Organization, Young People and
HIV/AIDS: Opportunity in Crisis (2002), p. 13.
\2\ Actionaid, The Sound of Silence: Difficulties in Communicating
on HIV/AIDS in Schools (2003).
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Claude Allen, Deputy Secretary of the Department of Health and
Human Services, has characterized the ``ABC'' educational strategy for
HIV/AIDS as follows: ``The ``A'' is for abstinence in young people, the
``B'' is for being faithful in a mutually monogamous relationship, and
the ``C'' is for condom use in high-risk populations with the knowledge
that condoms are highly effective in preventing HIV infection and
gonorrhea in men, but not as effective with all sexually transmitted
diseases.'' 3
---------------------------------------------------------------------------
\3\ Statement of Deputy Secretary Claude Allen before the
Subcommittee on Health, Committee on Energy and Commerce, March 20,
2003.
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Targeting abstinence messages at young people and limiting
information about condom use to ``high-risk'' populations (which we
take to mean high-risk persons other than the general population of
young people) is at odds with the recommendations of the Centers for
Disease Control and Prevention and the National Institutes of Health,
and of every major American medical professional association (including
the American Medical Association, the American Pediatric Association,
the American College of Obstetrics and Gynecologists, the American
Public Health Association, the American Psychological Association). All
of these groups have endorsed comprehensive sex education programs for
young people, including information about the use of condoms to prevent
HIV.
Of particular concern is that if Mr. Allen's vision of this
strategy is pursued, the ``ABC'' approach to HIV/AIDS prevention will,
in the case of young people, amount to an ``abstinence-only'' strategy
similar to that endorsed by the Bush Administration for domestic AIDS
prevention programs. The evidence is clear that comprehensive sex and
HIV/AIDS education programs and condom availability programs can be
effective in reducing high-risk sexual behaviors. There is, however, no
reliable evidence to date supporting abstinence-only programs. For
these reasons, the Institute of Medicine has expressed its concern that
``investing hundreds of millions of dollars of federal and state funds
. . . in abstinence-only programs with no evidence of effectiveness
constitutes poor fiscal and health policy,'' and recommended that
``Congress, as well as other federal, state and local policymakers,
eliminate requirements that public funds be used for abstinence-only
education, and that states and local school districts implement and
continue to support age-appropriate comprehensive sex education and
condom availability programs in schools.'' 4
---------------------------------------------------------------------------
\4\ Committee on HIV Prevention Strategies in the United States,
Institute of Medicine, No Time to Lose: Getting More from HIV
Prevention (Washington, D.C.: National Academy Press, 2001), pp. 118-
20.
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In many parts of the world, the engine of the epidemic is the
subordination of women and girls, which has particularly lethal
consequences in a world of HIV/AIDS. Regardless of cultural norms about
virginity and marriage, many women and girls are unable to negotiate
safer sex, or refuse unwanted sex; and, if they refuse or resist sex,
may be physically harmed or shunned from the household, thus risking
impoverishment. In this context, it is all the more important to
provide girls with complete information about HIV/AIDS prevention,
including condom use, while also addressing the underlying gender
inequalities that undermine women's and girls' control over their
sexual lives within and outside of marriage. (Obviously many other
measures are needed in addition to education and information programs
to ensure basic protections for women and girls from sexual violence
and abuse.5)
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\5\ See Human Rights Watch, Suffering in Silence: The Links Between
Human Rights Abuses and HIV Transmission to Girls in Zambia (2003)
(http://www.hrw.org/reports/2003/zambia/); Human Rights Watch, The War
Within The War: Sexual Violence Against Women and Girls In Eastern
Congo (2002) (http://www.hrw.org/reports/2002/drc/ ).
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Failure to teach about means of HIV prevention other than
abstinence endangers young people who are sexually active and limits
potentially life-saving information to all. Depriving young people of
life-saving information about HIV prevention violates their right to
information 6 and their right to the highest attainable
standard of health 7 and places them at needless risk of HIV
infection and premature death from AIDS.
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\6\ Everyone, including children, has the right to ``seek, receive
and impart information of all kinds.'' See International Covenant on
Civil and Political Rights (ICCPR), art. 19, and the Convention on the
Rights of the Child (CRC), art. 13.
\7\ All individuals have the right to enjoy the highest attainable
standard of health, a right guaranteed by the International Covenant on
Economic, Social and Cultural Rights, art. 12; the CRC, art. 24; and
the Convention on the Elimination of All Forms of Discrimination
Against Women (CEDAW), art. 12. According to the Committee on Economic,
Social and Cultural Rights, the right to the enjoyment of the highest
attainable standard of health includes the right to information and
education concerning prevailing health problems, their prevention and
their control. See Committee on Economic, Social and Cultural Rights,
General Comment 14. The Right to the Highest Attainable Standard of
Health, paras. 12(b), 16 and note 8.
---------------------------------------------------------------------------
A copy of Human Rights Watch research on federally funded
abstinence-only-until-marriage programs in Texas, which documents how
these programs censor or distort lifesaving HIV prevention, is attached
to this testimony.8
---------------------------------------------------------------------------
\8\ Human Rights Watch, Ignorance Only: HIV/AIDS, Human Rights and
Federally Funded Abstinence-Only Programs in the United States
(September 2002) (http://hrw.org/reports/2002/usa0902/).
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In conclusion, we believe it important that the government of the
United States make explicit, concrete commitments to protecting the
right to complete and accurate information about HIV/AIDS in the
programs it supports both in the U.S. and overseas. These programs
should include information for young people and adults on the use of
condoms for HIV prevention (A, B and C). Efforts to combat the
subordination of women and girls and to protecting them from sexual
violence, abuse and coercion should also be a central part of U.S.-
supported efforts to fight HIV/AIDS.
Sincerely,
Joanne Csete, Director
HIV/AIDS and Human Rights Program, Human Rights Watch
cc: Michael Bilirakis, Chairman, Subcommittee on Health