[Senate Hearing 108-242]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 108-242

  A MORAL IMPERATIVE: LEADER FRIST'S REPORT ON THE HIV/AIDS CODEL TO 
                                 AFRICA

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

                             JOINT HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON CHILDREN AND FAMILIES

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                                AND THE

                    SUBCOMMITTEE ON AFRICAN AFFAIRS

                                 OF THE

                     COMMITTEE ON FOREIGN RELATIONS
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                                   ON



  A REPORT FROM SENATOR FRIST RELATIVE TO THE HIV/AIDS CODEL TO AFRICA

                               __________

                            October 30, 2003

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions



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                            WASHINGTON : 2003
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  JUDD GREGG, New Hampshire, Chairman

BILL FRIST, Tennessee                EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming             CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri        BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio                    JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas                  JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama               PATTY MURRAY, Washington
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina    JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia             HILLARY RODHAM CLINTON, New York

                  Sharon R. Soderstrom, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                 ______

                 Subcommittee on Children and Families

                  LAMAR ALEXANDER, Tennessee, Chairman

MICHAEL B. ENZI, Wyoming             CHRISTOPHER J. DODD, Connecticut
CHRISTOPHER S. BOND, Missouri        TOM HARKIN, Iowa
MIKE DeWINE, Ohio                    JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas                  JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama               PATTY MURRAY, Washington
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina    JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia             HILLARY RODHAM CLINTON, New York

                   Marguerite Sallee, Staff Director

                 Grace A. Reef, Minority Staff Director

                                 ______

                     COMMITTEE ON FOREIGN RELATIONS

                  RICHARD G. LUGAR, Indiana, Chairman

CHUCK HAGEL, Nebraska                JOSEPH R. BIDEN JR., Delaware
LINCOLN D. CHAFEE, Rhode Island      PAUL S. SARBANES, Maryland
GEORGE ALLEN, Virginia               CHRISTOPHER J. DODD, Connecticut
SAM BROWNBACK, Kansas                JOHN F. KERRY, Massachusetts
MICHAEL B. ENZI, Wyoming             RUSSELL D. FEINGOLD, Wisconsin
GEORGE V. VOINOVICH, Ohio            BARBARA BOXER, California
LAMAR ALEXANDER, Tennessee           BILL NELSON, Florida
NORM COLEMAN, Minnesota              JOHN D. ROCKEFELLER IV, West 
JOHN E. SUNUNU, New Hampshire        Virginia
                                     JON S. CORZINE, New Jersey

                  Kenneth A. Myers Jr., Staff Director

              Antony J. Blinken, Democratic Staff Director

                                 ______

                    Subcommittee on African Affairs

                  LAMAR ALEXANDER, Tennessee, Chairman

SAM BROWNBACK, Kansas                RUSSELL D. FEINGOLD, Wisconsin
NORM COLEMAN, Minnesota              CHRISTOPHER J. DODD, Connecticut
JOHN E. SUNUNU, New Hampshire        BILL NELSON, Florida

                                  (ii)

  



                            C O N T E N T S

                               __________

                               STATEMENTS

                            October 30, 2003

                                                                   Page
Alexander, Hon. Lamar, a U.S. Senator from the State of 
  Tennessee, opening statement...................................     1
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee, 
  report.........................................................     2

                                 (iii)

  

 
  A MORAL IMPERATIVE: LEADER FRIST'S REPORT ON THE HIV/AIDS CODEL TO 
                                 AFRICA

                              ----------                              


                       THURSDAY, OCTOBER 30, 2003

                                       U.S. Senate,
Subcommittee on Children and Families, of the Committee on 
           Health, Education, Labor, and Pensions, and the 
      Subcommittee on African Affairs, of the Committee on 
                                         Foreign Relations,
                                                    Washington, DC.
    The subcommittees met jointly, pursuant to notice, at 3:04 
p.m., in room SD-430, Dirksen Senate Office Building, Senator 
Lamar Alexander (chairman of the subcommittee on Children and 
Families) presiding.
    Present: Senators Alexander, Enzi, Warner, Sessions, 
DeWine, Coleman, and Frist.

             OPENING STATEMENT OF SENATOR ALEXANDER

    Senator Alexander. The joint meeting of the Subcommittee on 
African Affairs and the Subcommittee on Children and Families 
will come to order. Good afternoon, and welcome to my 
colleagues and all those in the audience and those who may be 
watching on C-SPAN.
    This is a joint meeting of two of our subcommittees for the 
sole purpose of letting Majority Leader, Dr. Bill Frist, report 
on a mission that he led to Africa in late August which focused 
on HIV/AIDS. Five other Senators, including those who are here 
in the room, had the privilege of accompanying Dr. Frist. He is 
a little bit unusual. He is not only a doctor, he has educated 
the Senate and this country on the importance of the AIDS 
epidemic. So it was a remarkable experience for all of us.
    This meeting of our two subcommittees kicks off, or it 
begins what we hope will be a series of hearings that focuses 
on the President's commitment and the Senate and the House's 
commitment to work on this AIDS epidemic. I believe Ambassador 
Tobias is in the audience--is he here?--the President's global 
AIDS advisor. At least he is expected. We welcome him and look 
forward to working with him.
    We will go no later than 4 o'clock. In the interest of time 
and because we want to hear from Dr. Frist, I will forego an 
opening statement. We will listen to his presentation and after 
he is through we will simply go around the table and ask 
questions. This is more in the nature of a meeting than a 
hearing. We appreciate your time at this busy season of the 
Senate and look forward to your report. Our Majority Leader, 
Senator Frist.
    Senator Frist. Mr. Chairman, thank you, to my colleagues, 
welcome. Last month I had the privilege of traveling to the 
southern African nations of South Africa, Mozambique----
    Senator Alexander. Is your microphone on?

                    REPORT OF SENATOR FRIST

    Senator Frist. Last month I had the opportunity to travel 
to the South African nations which are depicted on the map 
behind me. That is South Africa, Mozambique, Botswana, and 
Namibia, with the Senators who are at the table today, notably, 
Senator John Warner, Senator Mike DeWine, Senator Mike Enzi, 
Senator Lamar Alexander, and Senator Norm Coleman, and also Dr. 
Joe O'Neill, deputy coordinator of the global HIV/AIDS office. 
I have had the wonderful opportunity to have visited Africa 
many, many times in the past so it was a real privilege for me 
to be able to join my colleagues as we explored together a part 
of Africa hat I had not traveled to before.
    As with my previous trips, I was struck by the optimism, by 
the perseverance, by the courage of the people that we had the 
opportunity to meet with, as well as their warmth, their 
compassion, their generosity, and their hospitality.
    Now the purpose of this delegation going to Africa was 
unique in many ways in that we had a very specific focus. That 
focus was to determine how best the United States can 
coordinate with others in this country and indeed around the 
world to address the global HIV/AIDS pandemic, which many of 
you have heard me describe as being the greatest humanitarian 
moral and public health challenge of the last 100 years. Our 
team, as you will see, had a productive trip. We met with 
doctors, patients, nurses, community leaders, government 
officials, and activists, all of whom are doing the very best 
they possibly can to fight this pandemic, and thereby bring 
hope and relief to millions of people.
    There is no part of world that has been more greatly 
affected by HIV/AIDS than the part of the world that we visited 
and that is southern Africa. Graca Machel, the truly remarkable 
First Lady of Mozambique, told us very directly that because of 
HIV/AIDS, ``We are facing extinction.'' We still face the worst 
of the epidemic, she told us. Let me repeat that. She said, 
``we are facing extinction.'' That is her evaluation and that 
is the challenge that is before us.
    I would like to organize my comments, not as a travelogue 
as we go through, but really in lessons that we as a group took 
away and lessons learned.
    Lesson number one, an effective, comprehensive response to 
HIV/AIDS requires the strong and the dedicated commitment of 
the national leaders. It has to start at the very, very top or 
no matter how much money you spend, how much money you invest, 
without that commitment at the top you simply, I believe, are 
not going to have the impact that we know that we can have. We 
met with the African leaders. We saw what an effective, 
comprehensive response to HIV/AIDS can result in if you have 
that national leadership. The leadership commitment has to 
start at the top with the leader of that country and then 
extend vertically all the way down to community leaders, all 
the way down to that local tribal leader.
    In South Africa, we met with the leaders in the local 
community who had been struggling with the political leaders in 
that country over the development of the appropriate treatment 
plans. I will come back to treatment here shortly. Treatment 
plans developed at the community level would save thousands of 
lives, but the people at the very top had not yet fully bought 
into the national commitment for treatment.
    Now that is changing. It was changing about the time that 
we were there, but until recently, very recently, the political 
leadership had failed at the top to adequately, I believe, 
address the reality of the virus. I believe it played a role in 
the fact that there are 5 million people in South Africa today 
who are infected with the HIV virus that causes AIDS. A virus 
for which there is no cure.
    In sharp contrast to that, in Gabarone, Botswana we met 
with President Festus Mogae, who in an effort to reduce the 
stigma and encourage nationwide testing, stood up and on 
television announced his HIV test results before the people of 
Botswana. Such unambiguous messages to the people have an 
impact.
    We have learned that. Again it is important because with 
every national leader that we see, not just in Africa but all 
around the world, we must look that leader in the eye and ask, 
what is your commitment, and encourage them to make that 
commitment. As a result, in Botswana we saw notable progress in 
fighting the pandemic, and in bringing understanding and 
security and the hope that we all know is so important.
    Lesson two, prevention, care and treatment. Those are the 
three building blocks, and people in public health understand 
that. But what is new is that the prevention and care must be 
linked to treatment. In HIV/AIDS, up until really pretty 
recently people said, no, we can leave the treatment off and 
let us just look at prevention and care. As you look at 
prevention, care and treatment, treatment must be preceded by 
testing so that the diagnosis can be made.
    What is not so intuitive, I think, is that testing, getting 
the test itself and knowing the results is the cornerstone of 
prevention. So if you just do prevention it is insufficient to 
have an impact unless you have a very strong testing program. 
The testing only takes 15 minutes. I say this as somebody who 
has been involved in public health and somebody who is a 
physician. The testing process gives what we refer to as a 
teachable moment that otherwise you just do not have. It is 
called a teachable moment because you have that 15 minutes that 
the test is taking place, that time where trust can be 
established, and in that teachable moment you have the 
opportunity to open people's eyes to the facts and to the hope 
of being able to address this disease.
    Now I say that because, and most people do not know this, 
in the world today of every 10 people who have the HIV virus, 
nine do not know it. So for every 10 people in this room today 
only one of those 10--assuming they were all infected, only one 
would know that they had HIV/AIDS. Now if you do not know you 
have it, you have the potential for spreading it and you are 
less invested in educating your own family or the people around 
you.
    In Kasane, Botswana we had the opportunity to look at these 
wonderful centers, Voluntary Counseling and Testing or ``VCT'' 
centers. In Kasane, Botswana and Namaacha, Mozambique we saw 
how using two simple tests a person could be tested in 15 
minutes while receiving counseling on how to avoid coming into 
contact with HIV/AIDS, and, if you happen to test HIV positive, 
how to prevent spreading that virus to others.
    The VCT test period takes overall typically one hour, about 
15 minutes on the test and the rest in counseling. You get the 
results of the test and then you go through further counseling. 
A person is encouraged to share that information with other 
people. If you test positive at that sitting, you can go into 
care, peer groups, and treatment if it is available. And if you 
are negative, through that teachable moment, you can learn how 
to educate your family and other people in your neighborhoods. 
Also it helps destigmatize. I will come to the stigma component 
in just a bit. This process is called VCT, voluntary counseling 
and testing.
    Lesson number three, we need to develop the medical 
infrastructure. This is very important, because there is this 
perception that if we just put money into buying drugs that we 
are going to be able to treat people with HIV/AIDS, prevent 
HIV/AIDS, or cure HIV/AIDS. What is obvious when you are in 
Africa, is that it is important to have that infrastructure 
itself to deliver treatment.
    President Bush's emergency plan for global HIV/AIDS calls 
for 2 million people to be on treatment by the year 2008. It is 
an ambitious goal, but we can meet that ambitious goal if we 
focus on ensuring that every taxpayer dollar that we invest, 
and we must be practical because we are talking about a total 
of $15 billion, we need to make sure it is invested wisely and 
at the appropriate time.
    The single largest challenge, perhaps, to meeting the HIV/
AIDS crisis in Africa through prevention, care and treatment is 
to develop this infrastructure to make sure that whatever is 
provided actually works. Medications must be stored properly 
and delivered properly. The infrastructure is necessary so that 
the patient can receive medical care over time. You need more 
than a diagnostic kit. You need more than medicines on the 
shelf. You need ways to deliver these drugs in a way that we 
know will be effective. The distribution, the storage, and ways 
to administer them.
    One message we heard again and again is the need for 
expertise and training. That is a way the United States can 
specifically help. In Botswana, Vice President Seretse Ian 
Khama and Minister of Health Lesego Motsumi stressed that their 
first priority is the recruiting and the retaining of qualified 
medical staff. All of our delegation will remember the images 
of the overworked staff who were dedicated and hard-working, 
but tired. You could see on their haggard faces their 
commitment. At the Chris Hani Baragwanath Hospital in Soweto, 
South Africa, my colleagues will remember the exhaustion on the 
faces of the staff as they stood into their busy HIV/AIDS ward 
with things coming and going and people being treated.
    We listened to the nurses, the doctors, and the social 
workers, of the desperate need for more and better trained 
social workers, for counselors to teach how to avoid and to 
cope with HIV infection, for technicians who are experts in the 
storage and disposal of medical waste, and for administrative 
staff. The United States can play a tremendous role in 
providing that medical expertise and in helping to create peer 
training.
    Lesson number four, we must provide care for the dying--the 
care component of care and treatment--and support for the 
living. Palliative care is an issue that came up often. What is 
palliative care? The Health Resources and Services 
Administration, HRSA, defines palliative care as patient and 
family-centered care that strives to optimize quality of life 
by anticipating, preventing, and treating suffering. Focusing 
on the continuum of illness, this care addresses not only the 
patient's physical needs, but also intellectual, emotional, 
social, and spiritual needs.
    So we asked, why is palliative care so important? It is 
important because HIV is a chronic disease that is fatal over 
time. It is a deadly illness that extracts not just a physical 
toll but also a spiritual toll, a psychological toll, on those 
people who are affected. And not just the people affected, AIDS 
impacts the families around them. As a physician I can tell you 
that HIV takes a toll, as I implied earlier, on health care 
workers as well. We have got to keep that morale up for health 
care workers or they will not stay in this palliative 
framework. We have got to keep the morale of the patient up, of 
the health care providers up, of the caregivers up, of the 
family up, of the loved ones. All of this will strengthen the 
health care system as a whole.
    Orphans. It is an issue that we have addressed in this very 
room in the past. Senator Jesse Helms really focused on the 
issue. He was almost the first to do so in our Government, and 
he made this link between HIV/AIDS and orphans. Graca Machel, 
who I referred to earlier, told our delegation of meeting an 
83-year-old grandfather in Uganda. I remember it so vividly 
when she said it. This 83-year-old grandfather had two wives, 
one 73 years of age, one 76 years of age. They were taking care 
of 30 grandchildren under the same roof because all eight of 
their children had died, had passed away leaving 30 
grandchildren. So caring for children left behind by AIDS is 
and must be a critical challenge in our response to HIV/AIDS.
    In South Africa we visited the Salvation Army's Carl 
Sithole Center. The center cares for 120 abused and 36 
abandoned HIV orphans, has a school right there that teaches 
225 children. The center is divided into Zodwa House for young 
children ages two through eight, and Bethany House for older 
children ages 8 to 18. The Carl Sithole Center accepted its 
first HIV positive child in 1993. That child's name was Copso 
which is the Sotho word for day of peace. Copso died at 4 years 
of age. Twenty-seven children have been buried in the memory 
garden of the last 10 years. Of the 128 children living in 
Bethany House, a third, one out of three, are HIV positive, and 
all, every one of the younger children at the Zodwa House are 
HIV positive.
    Windhoek, Namibia. We visited the Bernard Noordkamp Center 
run by the Catholic Church. It provides care and nutritional 
support and counseling to hundreds of orphaned children.
    Lesson number five, we must develop an approach to the AIDS 
crisis that is comprehensive and creative. There is no cure. We 
do not have that answer yet, and thus we need to develop more, 
not just comprehensive but innovative ways to respond to this 
pandemic.
    In South Africa we met with Dr. Fareed Abdullah, an 
exceptional health care professional with the vision to imagine 
a plan to bring universal treatment to those infected with HIV 
in the Western Cape area. Now this is almost an overwhelming 
task as you listen to him paint this picture, considering the 
Cape can expect a substantial health care burden within 7 years 
with an estimated 300,000 HIV-positive persons just living in 
this area of the Western Cape. Dr. Abdullah stressed that the 
AIDS pandemic has got to be tackled head-on and that nobody 
should view HIV/AIDS as a problem separated from traditional 
health care. He said we have got to make a virtue out of 
necessity. We can strengthen the failing health care system to 
fight HIV/AIDS only if we can think creatively and innovatively 
in terms of the approach. Otherwise it is simply overwhelming. 
We have got to find ways to leverage our ability to treat not 
just HIV/AIDS but HIV/AIDS within the overall health challenges 
a system must deal with.
    Senator Alexander. Excuse me, Senator. We have a vote that 
started at 3:16. I would assume that we could leave now and 
come back, or we could go another three or 4 minutes and come 
back.
    Senator Frist. What time is it right now?
    Senator Alexander. It says 25 after.
    Senator Frist. We have got to vote within 20 minutes.
    Senator Alexander. I thought you might want to be there.
    Senator Frist. How far are we into the vote?
    Senator Alexander. We are at 10 minutes into the vote.
    Senator Frist. Why don't I go for about three more minutes 
and then we will take a break.
    Senator Alexander. Then will you have time to come back for 
questions?
    Senator Frist. Absolutely. I just wanted to mention that 
HIV/AIDS affects the immune system of the body. We have this 
little virus, only 20 years old, that has killed 23 million 
people. When I was a resident in 1982 we had never heard of 
this virus. So it is a new virus that is having this impact. 
What it does, it knocks down your overall immune system and 
makes you susceptible to all sorts of other infections. That is 
why you cannot just treat the virus itself. You have got to 
have an overall infrastructure, a health care system and a 
systematic, a comprehensive approach to be able to treat all 
those infections and not just the little virus itself.
    That brings me to one final point, because by having 
something that makes you susceptible to other infections you 
need to consider water. There are about one billion people in 
the world today who do not have access to clean water. If it is 
not clean water, it can carry bacteria and viruses.
    Over 495 million people live in sub-Saharan Africa who do 
not have access to clean water today. As a result, 35,000 
people die every day. Ten thousand people are children who die 
each day from waterborne diseases. Ten million children die in 
developing countries before their fifth birthday, many in the 
first year of life. From all things that people die of, 75 
percent of the children are dying of infections of some sort, 
respiratory infections, diarrhea, malaria, measles, and 
malnutrition, or a combination of these conditions related to 
waterborne illnesses. Many of these deaths can be prevented by 
basic sanitation, hygiene, and access to clean drinking water.
    With that, Mr. Chairman, I think that is a good place to 
take a break and then we can slip back in. Is that appropriate?
    Senator Alexander. Thank you, Senator Frist. The Committee 
will take a brief recess. We should be able to be back and 
resume with Senator Frist's comments and then our questions 
after that.
    [Recess.]
    Senator Alexander. I think we should go ahead and take 
advantage of your time, Bill. What I failed to mention in the 
introduction of the Leader is that he also was the chairman of 
the African Affairs Subcommittee for a good while, so we 
especially welcome him for that reason.
    Mr. Leader, please continue.
    Senator Frist. Thank you, Mr. Chairman. We left a few 
minutes ago talking about this relationship between water and 
waterborne illnesses and HIV/AIDS. The reason this is so 
important, as we learned while we were in Africa, is it shows 
that it is more than just anti-retroviral drugs that you need 
for this pandemic to be reversed. As important as that anti-
retroviral drug might be, that you need to have a comprehensive 
approach. One of the ways you can do that is to make sure that 
people do have access to clean potable water.
    In Mozambique we visited a project to bring clean water to 
the citizens of Tshalala which is funded by a U.S. nonprofit 
called Living Water International, which is part of the 
Millennium Water Alliance. Living Water teaches people how to 
drill wells to the depth of about 30 meters and equips people 
with the tools and the knowledge to repair that equipment and 
to maintain it over time. At the same time, they provide 
instruction and training on sanitation and hygiene, and the 
people who learn these skills and techniques can teach them to 
other people.
    In Tshalala we saw a well with a simple hand pump that 
provides an estimated 300 to 400 people with adequate drinking 
and bathing water. The cost is about $2,800. The average cost 
of such a well in Mozambique is about $2,500. If you divide 
that out it comes down to about $8 per person. Using that $8 
per person we can prevent, through clean drinking and bathing 
water, a number of otherwise life-threatening diseases, and 
provide a savings for overworked, underfunded national health 
systems through preventive care.
    Lesson six, partnerships. Partnerships, partnerships, 
partnerships. Partnerships between government which we 
represent, NGOs that are so critical on the ground. 
Partnerships with the academies or universities of the world. 
Partnerships with private sector companies. Partnerships with 
pharmaceutical companies. Partnerships with faith-based 
initiatives. The only way, I believe, and I think that we all 
learned, to meet the immediate so-called capacity needs is to 
build these strong and effective partnerships. No one group can 
do it alone.
    In Botswana we visited the appropriately named Masa, and 
that means ``new dawn,'' Clinic. Masa is funded by the African 
Comprehensive HIV/AIDS program, ACHAP. You will see ACHAP a 
lot, ACHAP also supports the Coping Centers for People Living 
With HIV/AIDS as well as the Botswana Christian AIDS 
Intervention program. ACHAP is a unique partnership sponsored--
again, partnerships--by the Bill and Melinda Gates Foundation, 
the Merck Pharmaceutical Company and the government of 
Botswana. A remarkable program launched in July 2000, now about 
3 years ago, ACHAP provides free anti-retroviral treatment, 
counseling, care--prevention, care and treatment for 600 
Africans.
    What is fascinating to me as a physician is that patients 
in the Masa program have a compliance rate of around 90 to 100 
percent in following the prescribed drug regimen. Again this is 
important because in Africa you have heard it said, people are 
not going to comply. I can tell you that is higher than most 
every western country. The western country average is probably 
about 20 percent less than that in terms of compliance.
    In South Africa we also visited a company called Anglo-Gold 
Mining. The Anglo-Gold Mining's anti-retroviral treatment 
program was established to bring anti-retroviral treatment to 
HIV-infected employees. The natural question is, how many 
employees is that? In this huge, huge country it is estimated 
that about one out of three employees are HIV positive, one out 
of three.
    In Rehoboth, Namibia we visited St. Mary's Hospital which 
is preventing new infections through President Bush's 
initiative. It was wonderful for our delegation to see these 
initiatives on the ground playing out in action. This 
initiative is the prevention of mother-to-child transmission 
program. It uses nevirapine, an inexpensive drug, which using a 
single dose, has a huge impact. But it was great to see that 
program on the ground implementing President Bush's initiative.
    Lesson seven, we have got to reach people where they live. 
Most Africans live outside of the urban areas. They do not have 
access to hospitals, clinics, or health care facilities. We saw 
a lot of creative responses to the problem.
    In Carletonville, South Africa we saw mobile clinics. The 
mobile clinics are vans which have trained personnel and 
medical equipment. They go out into the bush throughout that 
region in Africa and bring basic care to treat persons in these 
communities that are a long way from the nearest health care 
facility.
    In Kasane, Botswana we saw a mobile rapid testing lab which 
travels through the Kasane region. That is in the north part of 
Botswana. By closing the gap between people and health care 
providers we are able to strengthen the capacity to deliver 
health care to cope with HIV/AIDS. It provides that structure 
through which HIV/AIDS can be adequately, appropriately, and 
effectively addressed.
    Lesson eight, we must take steps to reduce the stigma--I 
mentioned the stigma earlier of HIV--through all sorts of 
means. Through messages, through communication tools. We know 
which communication tools work today. Let me just say up front, 
stigma is a universal barrier. The stigma of HIV/AIDS is 
prevalent in this country today. This is a universal challenge 
that we have. As we look to reach out to people, remember nine 
out of 10 people in the world who are HIV positive do not know 
they are positive. Why? Much of it has to do with the stigma.
    Because of stigma and the fear of discrimination, African 
women told us again and again, they are afraid of getting 
tested out of the fear of retribution. From who? The person 
next to them, their husband. Some men are afraid to be tested 
out of fear of being shunned by who? People who they work with, 
or shunned by their neighbors. Stigma, obviously makes people 
reluctant to come forward for testing. It makes people 
reluctant even to talk about the HIV/AIDS virus. In this 
country it is the same thing. How many parents really sit down 
and talk to their children today about HIV/AIDS? So it is a 
universal challenge that we have.
    I mentioned earlier the importance of political leaders. 
Political leaders need to get out front on the issue. Obviously 
President Bush has done that in a bold, creative way. He stood 
up before the American people and, indeed, the world community 
saying that this is something that we as leaders in this 
country must and will address.
    You can eliminate or reduce stigma by giving the 
appropriate message. In Mozambique, again former First Lady 
Graca Machel told us of the difficulty in addressing HIV/AIDS. 
She has a foundation set up to address this called Foundation 
for Community Development. She told us how her foundation works 
with faith-based organizations to reduce that stigma of HIV/
AIDS. She said that one of the more effective ways that she 
found was to use individual Bible verses to connect with 
people, church-going, faithful people, spiritual people. By 
using these Bible verses, FDC was able to connect in a unique 
way and reduce that sense of what she described as shame. 
Again, it is a technique which she says is working well.
    She also reminded us of the importance of creating tactical 
ads to appeal to men very specifically on the dangers of sexual 
promiscuity. She shared her thoughts as well on the multiple 
media sources, the use of radio and billboards and hotlines, 
all of which she has incorporated into her program. The 
knowledge of HIV/AIDS and all the science that we have and the 
ability to help does little good unless we can get it out to 
people around the world so that they hear it and so that they 
understand it.
    One of the more meaningful interactions we had was with the 
traditional healers. You know I am a doctor and I am trained in 
western medicine. I do heart transplants and heart and lung 
surgery. All that is good, but the people who are trusted in 
communities on the ground throughout Africa and other parts of 
the world are the traditional healers. They are the people who 
are the leaders in the community. They are the people who are 
actually trusted. In Botswana we were informed that as much as 
85 percent of the population will visit those traditional 
healers, the spiritualist, the herbalist, the diviners, and 
other practitioners of traditional medicine. In Mozambique we 
met with traditional healers from 10 different villages. They 
are trusted local healers and that is to whom people turn for 
treatment, for counseling. What was exciting to us is that 
these traditional healers are reaching out to know more about 
that little tiny virus that has killed 23 million people. That 
linkage with those traditional healers I am very excited about, 
especially with those healers reaching out for an understanding 
of this virus, because it comes down to trust, and that is the 
way to best destigmatize this virus.
    Over the long-term we have got to work toward developing 
guidelines for medical personnel to make HIV a more routine 
part of health testing. Last week, I was very pleased to see 
that President Mogae of Botswana announced a new government 
policy on routine HIV testing in Botswana.
    Let me go through one more lesson, Lesson nine. We have got 
to envision a future without HIV/AIDS. Remember, this little 
tiny virus was not known in this country until about 1983, and 
again, I had the opportunity of training at some very good 
hospitals in the United States of America with the very best of 
what we have to offer. We had no idea that this little virus 
existed and we had not defined it until between 1981 and 1983.
    Twenty-three million people have died. Forty million people 
are infected now. Again, this is around the world. It is likely 
another 60 million people are going to die unless we act, act 
as a Nation and as a global community. But we need to envision 
this future without AIDS. It is overwhelming what is happening. 
Even if we get the disease under control we have got to think 
ahead right now, and it is not just vaccine development to 
imagine a world without HIV/AIDS. In all the countries that we 
traveled, in each of these countries we were met with a lot of 
hope and optimism about the future. It was expressed in many 
ways, hope that we would have better trade agreements to 
empower people, to empower their economies, hope for a more 
prosperous life. People with HIV/AIDS or with infected family 
members, hope for a more prosperous life with their families. 
In spite of the impact of this terrible and devastating 
disease, Africans are very hopeful and truly believe in the 
future. We have a moral obligation to stand by them and to 
maximize their opportunity for growth and for that posterity.
    Mr. Chairman, let me just close, and thank the ambassadors 
from the United States of America and their staff because they 
really made it possible to open up their countries for our 
delegation to visit over this period of time. Ambassador 
Cameron Hume in South Africa, Deputy Chief of Mission Dennis 
Hankins in Mozambique, Ambassador Joe Huggins in Botswana, and 
Ambassador Kevin McGuire in Namibia. They gave us outstanding 
support and assistance by opening up their homes to our 
delegation, working overtime to make our trip successful, and 
for that we are grateful. They are a real credit to the State 
Department and the United States, and they represent, as we had 
the opportunity to see on the ground, the American people 
admirably.
    Thank you, Mr. Chairman. That is a quick overview in terms 
of a fascinating trip. There is so much more to talk about, but 
I did want to stress these nine lessons so that we can all best 
figure out how to address this largest and most significant 
humanitarian challenge of our times.
    Senator Alexander. Thank you, Senator Frist. On behalf of 
all of us I would like to thank you and your staff for that 
presentation, and for putting together such an effective trip. 
I rarely spent 10 or 11 days so efficiently and learning as 
much as we did.
    We have a little time. We probably need to end this about 5 
after 4:00 because of the Republican Conference, but let us see 
if we can each get in a question. I will ask one, and then go 
to Senator Warner, and Senator DeWine, Senator Enzi, Senator 
Coleman.
    You mentioned political leadership at the beginning of your 
talk, and we saw examples of impressive political leadership in 
the four countries we visited. We have talked about a lot of 
problems, but we also saw a lot of good government, and of 
course in South Africa we saw a political miracle, which is 
what has happened there in the last 10 years. The surprise of 
the trip probably was the exchange you had, and others of us 
had, with some of the political leadership in South Africa 
which had been slow to respond to the AIDS epidemic. Do you 
have any reflections on that and have you seen any changes in 
that since the time we were there?
    Senator Frist. Thank you, Mr. Chairman. What was remarkable 
was the juxtaposition of leadership that was in the process of 
changing plus leadership that had already changed at the 
highest level. South Africa, for the last 5 years--and let me 
say there have been dramatic changes in the last 3 months, 
dramatic changes--but for the last several years there has been 
denial and there have been reasons given in terms of what HIV/
AIDS was caused by. With that denial there was not a walking 
away but a lack of recognition. Unless you say that there is a 
problem, you are not going to be able to move in with 
prevention, care and treatment. That has changed, and it has 
changed at the highest level, with the President of that 
country. So I am a little hesitant to be critical of the past 
because I am so delighted to see a huge change there and by the 
Minister of Health.
    Then we saw countries like Botswana where the leadership 
was out getting that test, saying to the people all across the 
country that this is a problem and you can see that I am going 
to be on the forefront to reverse this. Otherwise, we will face 
the inevitable course of a worsening pandemic.
    Senator Alexander. Senator Warner.
    Senator Warner. Thank you, Mr. Chairman. First, I commend 
you for having this meeting because in my 25 years in the 
Senate I have been on a fair share of CODELs, and they are 
misunderstood. It is part of the continuing educational process 
of the Senate to go out and visit the countries abroad and to 
come back, as we are doing, and share with our colleagues and 
others our own observations.
    But first, Mr. Leader, a little observation here. You 
overlooked something that is very important in this report, and 
that is reference to the fact that each of you brought your 
wives and they were an integral part, seriously, of this CODEL. 
They were able to interrelate with others, and particularly 
some of the females that we met I think in a way that none of 
us could have done so. So I would hope that you would revise 
these remarks to include reference to that.
    Senator Alexander. Yes, sir, sure will.
    Senator Warner. On another matter, I felt that--and I have 
talked to the military leaders in my capacity as Chairman of 
the Armed Services Committee in the various countries, and I 
was shocked to learn how AIDS is affecting their ability to 
conscript and train adequate forces to maintain the political 
stability as well as the strategic stability of these countries 
emerging from colonialism and fighting the struggle to become 
independent and strong nations.
    For example, the UN is raising peacekeepers to go into a 
number of areas. There are about 6 areas where there is open 
warfare in the African continent today. They go to the various 
nations and ask for several battalions, and when those nations 
put the battalions together they have to strip out significant 
numbers of the trained soldiers because they have HIV, because 
they do not want to send an HIV to another nation. Often it is 
difficult to raise the number of troops that they need.
    I saw that--as you know, I left you for a day or two to go 
to Liberia, where at that time our forces had intervened and 
were continuing to intervene to maintain peace and stability, 
and they did it in a very successful way thus far in Liberia. 
There is a nation that is utterly devastated by 12 years of 
civil war. Superimposed on that are the horrors of the AIDS 
epidemic.
    So I am delighted that you took the initiative that you 
included all of us, and we commend you.
    Senator Frist. Mr. Chairman, let me jump in real quick 
because I think that Senator Warner really pointed out the 
pervasive effect that HIV/AIDS has in the most productive years 
of a population. When you go to parts of Africa you see very 
young children running around, and then you see people much 
older, and whether it is a teacher, military personnel, leaders 
in civil society, people are losing the people in the most 
productive years of their lives because of this virus.
    Senator Alexander. I think we ought to also add that in the 
few minutes that Senator Frist allowed us to have free time, 
Senator Warner often took the Marines who were stationed out to 
dinner, which impressed me.
    Senator DeWine.
    Senator DeWine. Mr. Leader, thank you for leading that 
trip. It was an excellent trip and a great educational 
experience for all of us.
    Your presentation, I think, outlined a lot of what we 
learned and outlined many of the challenges that we face and 
these countries face. It seems to me that we have a long-term 
challenge and a short-term challenge. The short-term challenge 
that we have and these countries face is to deal with the 
crisis as quickly as we can. We are in the process of 
appropriating money. The first question is how do we get this 
money out quickly to save as many lives as we can? The second 
question is, as you have pointed out, we have got a health 
infrastructure challenge, a medical infrastructure you call it, 
which is a long-term problem, and how do we deal with that?
    I wonder if you could reflect on both the short-term 
challenge that we face; how do we make sure those dollars are 
spent correctly to save as many lives as quickly as we can? But 
also the long-term challenge--the 2-, 3-, 4-, 5-years and 
beyond--of how we help them with their health infrastructure 
which in the long run will also save, we hope, hundreds of 
thousands, maybe millions of lives?
    Senator Frist. Thank you. I think that is a good way to 
dissect the problem because if you have a dollar to invest, you 
have to decide how to invest that dollar so that it will have 
the greatest impact. You cannot think just short-term, because 
you could take not just $15 billion over 5 years, which is 
huge, you could take hundreds of billions of dollars, and if 
you did not invest it wisely, it would be not wasted, but it 
would not have anywhere near the potential impact.
    So challenge number one, short term we need to identify 
programs that work because there are things that we know work 
in terms of prevention, care and treatment. We do have a 20-
year history. We have places like Uganda and we need to 
replicate the programs that are developed there, namely, what I 
talked about, VCT, voluntary counseling and testing. It is a 
model. They had a curve like the curves in Southern Africa, 
where things are getting worse, and they now have reversed that 
curve in Uganda. It is going down. Thus, we need to do what 
they did.
    Chairman Warner is exactly right. The effective use of our 
time is to go through and see firsthand what works based on 
models that work, and that is where we need to be investing our 
money in the short term, not just taking a dollar and spending 
it by giving it to a group that is not proven. There are 
unlimited groups who want money. Having Dr. O'Neill with us, 
who represented the administration, allowed him to see some of 
those programs.
    Longer term, and the continuum itself, we need to even jump 
further ahead than was in your question because we do not have 
a cure. This little virus is a cagey virus. It moves about 
100,000 times faster than most other viruses. If you develop 
something we think is going to cure it, it just changes face 
and becomes something else. We have to figure that out. That 
means the science in this country must improve, taking the 
smartest people in the United States of America and around the 
world, and investing part of that dollar there because no 
matter how much we do in prevention and care, if you cannot 
cure it long-term, you are not going to be able to eradicate 
this virus. We can do it. As you know, smallpox has been 
eradicated. That killed about 340 million people. So I would 
jump even further ahead.
    That is the spectrum itself, programs we know work all the 
way to finding an actual cure. In that we are going to have to 
make decisions throughout, and I am confident we can do that by 
having the sort of experiences that we all shared together 2 
months ago.
    Senator Alexander. We have two more questions. We have a 
vote with 11 minutes left. That ought to wrap things up neatly. 
Senator Enzi.
    Senator Enzi. Mr. Chairman, I thank you for holding this. I 
think this itself is an unusual event for one of the trips to 
pull back together to discuss some of the information that was 
on it. I thank the Chairman for doing it. It was just an 
incredible cultural shock for me to go over there. Mozambique 
has 11 different languages and then each tribe has their own 
dialect of that, and we wonder how do you communicate under 
these circumstances? None of them own a TV because they are too 
poor to own a TV. They would be lucky if they owned a radio. 
They do not subscribe to a newspaper because you are not going 
to print a newspaper for a couple of hundred people. So just 
getting the message out is difficult. I had never appreciated 
the possibility of the prevention of mother-to-child 
transmission, which is one of the real hopes that I saw out of 
the trip. For $2.50 the mother gets a dosage of a drug she 
takes when she goes into labor. The child gets a liquid dose 
right after birth. It prevents 95 percent of the mother-to-
child transmission. Of course they have to have that testing 
that you talked about to be able to do that.
    But even more basic than that was that water problem that 
you showed on your slides. Mozambique hopes that some day 
everybody will be within 5 miles of water, and in that they are 
counting ponds that they wash their clothes in, swim in and 
have their animals drink out of. For $6 million we could solve 
a water problem over there.
    Did we include in anything that we are doing financially--
in other words, money that could be utilized to help out on 
that water problem, which is such a basic thing?
    Senator Frist. The water issue is just fascinating in terms 
of the prevention of disease by a very small investment over 
time. I hope it is part of the comprehensive program that the 
President is developing with Mr. Tobias, who we will have the 
opportunity to meet with later today. But that planning is 
under way and that comprehensive approach, not just of getting 
a medicine, anti-retroviral therapy, but the comprehensive 
approach indeed should be part of the President's initiative 
for combating and reversing this pandemic.
    Senator Alexander. Senator Coleman.
    Senator Coleman. Thank you, Mr. Chairman. Mr. Chairman, 
thank you for pulling this hearing together. It has just been 
absolutely fascinating. Mr. Leader, I really think we are 
blessed to have your leadership at this time in this body with 
your understanding of this issue that is just taking so many 
lives it is almost mind boggling. But you give us hope by your 
passion and your commitment.
    One of the things I notice about hope--and it was the 
difference between the doctors at the Krishani facility in 
South Africa where at that time there were 5 million people HIV 
positive, 20,000 being treated, I think they just got a letter 
that said they could do some treatment, but they were tired, 
their eyes were tired. They were treating people, they were 
dealing with people who were going to die and there was no 
treatment. I contrasted that with the look on the face of the 
healers at the Masa ARV facility in Botswana, who were treating 
people, and they were lined up, and the backlog was actually in 
processing some of the testing. I am a passionate believer in 
treatment, in terms of extending lives, keeping moms alive so 
that people are not orphaned for many, many years, and what it 
does to the healers to keep the system going.
    Is there a way to set up measurables? Can we go back with 
the money we have to go back and say, okay, you have been 
treating this many folks now. We expect over a certain period 
of time to try to have some standards by which we can measure 
the kind of growth and the impact because we know how important 
it is.
    Senator Frist. The measures are critical. Again, if we had 
the answers now in terms of a cure, it probably would not be as 
important because basically once you have the medicines all the 
way to the delivery point, and you knew they were going to have 
an impact, that the virus was going to go away, then it 
probably would be less important. The problem is we are in the 
learning curve. I mentioned Uganda, Senegal. These are the 
great success stories that we have and we can replicate today.
    What the President's initiative does is set out in very 
specific terms both numbers and accountable measures throughout 
the program to make sure that the money that is invested, huge 
sums, unprecedented sums in the history of any nation on earth 
today, has its outcome measured along the way. So that if we 
invest two billion dollars this year and a little bit more that 
next year, a little bit more that next year, we would be able 
to invest that incremental amount in the most useful way based 
on what we are learning right now in the program, as has been 
done in Uganda.
    One of the beautiful things about this very targeted 
initiative, is that instead of saying we are going to throw 
money at the problem, it is being done in a way that is 
organized, that is disciplined, that has quantifiable measures 
in terms of outcome, both in terms of quality as well as 
quantity as we go forward. That is what I am most excited 
about, and again, that is why it is important that as we 
recognize that it is not just the amount of money which is what 
a lot of people around the country measure. It is also about 
ensuring that that money is invested wisely in programs that 
work.
    Senator Alexander. Senator Frist, thank you for your 
leadership. Thank you for your presentation.
    These two Subcommittees representing the Health, Education, 
Labor, and Pensions Committee and the Foreign Relations 
Committee will continue to meet together. We look forward to 
hearing from Ambassador Tobias on his plan for the $15 billion 
that the President has recommended and that the Congress has 
said it will spend, and we invite you to any of those hearings 
that you have time to attend. Thank you very much.
    The Committee meeting is adjourned.
    [Whereupon, at 4:10 p.m., the Joint Committee was 
adjourned.]