[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]




                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                        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/


                            WASHINGTON : 2003
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               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
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
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
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)
W.J. ``BILLY'' TAUZIN, Louisiana
  (Ex Officio)


                            C O N T E N T S


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





                        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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    You can go for 1 minute, if you would, and then if you 
would maybe defer.


    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 
    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 
    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 
    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 
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 
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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    Mr. Bilirakis. Thank you, Mr. Secretary. Ms. Capps to 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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 
    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.

    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 
    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.

    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.

    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 
    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 

                           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 
    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 
    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 
    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 
    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 
    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 
    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.


    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 

     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.


    Hearst, N., and S. Chen. (2003). Condoms for AIDS Prevention In The 
Developing World: a Review Of The Scientific Literature. Geneva: 
    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 
    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 
    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 
    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 
    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 
    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
    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.


    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: 
    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.
          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 
    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 
    Thank you, again, for the opportunity to testify before your 
committee, and to respond to your questions.
                                             Shepherd Smith
                                         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 
 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 
 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 
   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.
    \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).
    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, 
    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 
    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-
    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)
    \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/ ).
    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.
    \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/).
    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.
                                     Joanne Csete, Director
              HIV/AIDS and Human Rights Program, Human Rights Watch
cc: Michael Bilirakis, Chairman, Subcommittee on Health