[Senate Hearing 108-616]
[From the U.S. Government Printing Office]

                                                        S. Hrg. 108-616


                               BEFORE THE

                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION


                              MAY 11, 2004


       Printed for the use of the Committee on Foreign Relations

 Available via the World Wide Web: http://www.access.gpo.gov/congress/


                  RICHARD G. LUGAR, Indiana, Chairman
CHUCK HAGEL, Nebraska                JOSEPH R. BIDEN, Jr., Delaware
LINCOLN 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


                            C O N T E N T S


Boxer, Hon. Barbara., U.S. Senator from California, submissions 
  for the record:
    ``Iraq Prison Scandal; A Double Ordeal for Female 
      Prisoners,'' article from the Los Angeles Times, May 11, 
      2004.......................................................    57
    Letter to Ambassador Randall Tobias, dated March 26, 2004, 
      expressing serious concerns of efforts to block affordable 
      generic HIV/AIDS drugs, from 370 national and international 
      organization...............................................    58
Catholic Relief Services, Baltimore, MD, position paper and 
  additional material and charts, submission for the record......    65
Coalition for Food Aid, Washington, DC, letter to Senator Lugar, 
  dated April 27, 2004, transmitting information for the record..    86
Feingold, Hon. Russell D., U.S. Senator from Wisconsin, prepared 
  statement......................................................    38
Lugar, Hon. Richard G., U.S. Senator from Indiana, opening 
  statement......................................................     1
Morris, Hon. James T., Executive Director, World Food Program, 
  United Nations, New York, NY...................................     4
    Prepared statement...........................................     9
    World Food Program news release, dated May 11, 2004, titled 
      ``AIDS Complicating Battle Against Hunger, Says WFP 
      Executive Director''.......................................    13
Natsios, Hon. Andrew S., Administrator, U.S. Agency for 
  International Development, Washington, DC......................    18
    Prepared statement...........................................    21
    ``Nutrition and HIV/AIDS: Evidence, Gaps, and Priority 
      Actions,'' a research paper prepared jointly by the Academy 
      for Educational Development and USAID, submission for the 
      record.....................................................    24
    Cable to USAID field missions: sent by Administrator Natsios 
      on June 1, 2001............................................    32
Tobias, Hon. Randall L., Global AIDS Coordinator, U.S. Department 
  of State, Washington, DC.......................................    14
    Prepared statement...........................................    21
World Vision, ``Integration of Food Security and HIV/AIDS 
  Programming: A Rapid Review of World Vision's Experience and 
  Lessons Learned,'' a series of briefing charts submitted for 
  the record.....................................................    88





                         TUESDAY, MAY 11, 2004

                                       U.S. Senate,
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The committee met at 10:02 a.m., in room SD-419, Dirksen 
Senate Office Building, Hon. Richard G. Lugar (chairman of the 
committee), presiding.
    Present: Senators Lugar, Alexander, Feingold, and Boxer.

        opening statement of senator richard g. lugar, chairman

    The Chairman. This meeting of the Senate Foreign Relations 
Committee is called to order.
    During the past 16 months, the Foreign Relations Committee, 
on multiple occasions, has addressed the horrific consequences 
of the HIV/AIDS pandemic and global hunger. We are charged with 
overseeing international food assistance and the implementation 
of the United States Leadership Against HIV/AIDS, Tuberculosis, 
and Malaria Act of 2003, which was signed into law last May. 
This 5-year, $15 billion initiative is unprecedented in its 
scope and its importance.
    In February 2003, we held a hearing on global hunger 
issues. The hearing reminded us that in many parts of the 
world, food shortages are resulting in massive loss of life and 
threatening regional security. At that hearing, the issue of 
the AIDS crisis and its impact on food security was raised 
repeatedly. Today we intend to focus specifically on this 
catastrophic connection between the AIDS pandemic and hunger.
    This hearing was originally scheduled for February 4 of 
this year, but was canceled due to the ricin incident that 
closed the Senate office buildings. We are fortunate to have 
another opportunity to pursue this important topic today. I 
want to thank our distinguished witnesses for their patience 
and their willingness to work with us in the rescheduling of 
the hearing.
    We welcome today three close friends who have applied their 
extraordinary talents to bringing hope and relief to people 
around the world. We will hear from James Morris, Executive 
Director of the World Food Program; Ambassador Randall Tobias, 
Global AIDS Coordinator; and Andrew Natsios, Administrator of 
the U.S. Agency for International Development. It is a personal 
privilege to introduce fellow Hoosiers Jim Morris and Randy 
Tobias. Indiana is proud of the work they are doing. I also 
would extend a very warm welcome to Andrew Natsios who has been 
a good friend of the Foreign Relations Committee and is working 
closely with us on many projects.
    I would note parenthetically that Secretary General Kofi 
Annan sent Jim Morris to head a U.N. humanitarian assessment 
mission to the Darfur region of Sudan less than 2 weeks ago. 
His findings have been reported to the Security Council. He may 
wish to comment, to the degree that he can, on the disturbing 
situation that has seized the attention of the world in that 
    Given the infrequent opportunity to bring together all 
three of these well-traveled public servants, our hearing today 
is devoted to giving committee members an extended opportunity 
to engage with them. However, we also recognize the critical 
contributions of private voluntary organizations in addressing 
the twin problems of AIDS and hunger. Last week committee staff 
received an extensive briefing on this topic from members of 
the NGO community, including CARE, World Vision, and Catholic 
Relief Services. These private voluntary organizations are on 
the front lines in confronting AIDS and hunger, and we will 
continue to tap their extensive expertise.
    Most of us by now are well aware of the devastation caused 
by the AIDS crisis. We have heard the figures: approximately 40 
million people around the world are currently living with HIV. 
The epidemic killed more than 3 million people last year. 
Similarly, many of us know that millions of people go to bed 
hungry every night and that many, especially children, die of 
malnutrition caused by food shortages or famine.
    What many people do not realize, however, is how each of 
these two crises exacerbate the conditions that contribute to 
the other. It is no coincidence that the prevalence of HIV/AIDS 
is highest in countries where food is most scarce. Because the 
disease affects people in their productive years, it has 
decimated the agricultural sector of sub-Saharan Africa, where 
approximately 80 percent of the population depends upon small-
scale subsistence agriculture for their livelihood and food. 
Since 1985, more than 7 million agricultural workers have died 
of AIDS in 25 African countries. This places the burden of 
producing food on children and the elderly. In many places, 
fields lay untended with no one to work them. The AIDS crisis 
has left some 14 million orphans without parents to farm or 
otherwise provide food. In many rural households, AIDS has 
turned what used to be a food shortage into a food crisis.
    This food crisis, in turn, is accelerating the devastation 
of AIDS. Without high-protein, nutrient-rich food, HIV-positive 
individuals become weaker, do not respond to drug treatment, 
and are more susceptible to other illnesses such as 
tuberculosis. Good nutrition is crucial for helping HIV-
positive individuals maintain their strength and productivity 
as long as possible. This means that parents can continue to 
care for their children, teachers can continue to teach, and 
farmers can continue to farm. The head of UNAIDS, Peter Piot, 
said that when visited by relief workers, often the first thing 
people with AIDS ask for is not care or drugs or relief from 
stigma; they ask for food.
    Food assistance is essential if we are going to make any 
headway in the struggle against the virus. Today we have a 
unique opportunity to explore the relationship between these 
deadly crises. If we are serious about battling the AIDS 
epidemic, it is imperative we fully understand the AIDS-hunger 
cycle and examine our response to both problems in relation to 
each other. According to the World Food Program, more than 
24,000 people die daily from hunger and related causes. 
According to USAID, nearly 8,500 people die daily from AIDS, 
and an estimated 14,000 people are infected every day. Every 14 
seconds, as a matter of fact, AIDS turns a child into an 
orphan. Clearly we cannot afford to waste a single day in 
developing the most effective response possible.
    In addition to exploring the complex dynamic between AIDS 
and hunger, we will discuss U.S. and multilateral efforts to 
address these related crises, including those of the Department 
of State, USAID, and the World Food Program. I am optimistic 
that today's discussion will enable us to understand more 
completely the deadly nexus between AIDS and hunger and to move 
forward on a more effective policy for their eradication.
    I will, of course, yield to the distinguished Senator from 
Delaware, Senator Biden, should he attend later this hearing, 
for any statement that he may have.
    I will ask Senator Boxer, who is here, if she has an 
opening comment for this hearing.
    Senator Boxer. With your indulgence, Mr. Chairman, I would 
like to take just about 2 or 3 minutes here to thank you so 
much for holding this important hearing on the relationship 
between hunger and HIV/AIDS.
    While this relationship is often overlooked, I am confident 
that this hearing will leave little doubt that these two issues 
are linked. You cannot prevent and treat AIDS without also 
addressing malnutrition, hunger, and poverty. Malnutrition 
makes AIDS sufferers so weak that they cannot work in their 
fields to feed themselves and their families. Lack of food 
leads to malnutrition and a weakened immune system. A weakened 
immune system makes one more vulnerable to AIDS. So, Mr. 
Chairman, what you have hit upon today is this deadly cycle.
    The impact of this terrible epidemic is becoming clearer 
every day. As you said, there are an estimated 40 million 
people living with HIV/AIDS in the world. I come from the 
largest State in the Union. We have 35 million people in our 
State. So you could just think about every single person in my 
State suffering from HIV/AIDS, what that would do.
    In closing, let me just throw a couple of statistics out 
here. Five million people were newly infected in 2003. Three 
million people died last year as a result of AIDS. Seven 
million agricultural workers in Africa have died of AIDS since 
1985. And 16 million more agricultural workers in Africa could 
die by 2020. The most affected African countries could lose up 
to 26 percent of their agricultural labor force within the next 
two decades, and last, according to Bread for the World, HIV/
AIDS and food insecurity have a disproportionate impact on 
women. Women are more vulnerable physically and culturally to 
HIV infection. At the same time, women produce up to 80 percent 
of the total food supply in sub-Saharan Africa.
    So, Mr. Chairman, you have called it a crisis. You are 
right, but it is almost that there is no word that we could 
truly use today to describe this. I just want to again thank 
you very much for your leadership.
    The Chairman. Thank you very much, Senator Boxer.
    We turn now to our three witnesses. First of all, I will 
mention that the text of your messages will be made part of the 
record in their entirety. Summarize if you wish or proceed in 
any way, but the purpose of the hearing really is to hear from 
you and to have as complete an understanding as possible of the 
interconnection and the importance of the subject matter.
    I would like for the witnesses to testify in this order: 
first of all, James Morris; second, Randall Tobias; and third, 
Andrew Natsios. I introduce, first of all, the Honorable James 
G. Morris, Executive Director of the World Food Program of the 
United Nations, headquartered in New York, New York, but 
likewise in Rome, Italy where much of his time is spent. Jim, 
would you please proceed.


    Mr. Morris. Thank you, Mr. Chairman, Senator Boxer. First, 
thank you both for your extraordinary, insightful opening 
statements. You have described the problem perfectly. Also, 
thank you for having met with CARE and World Vision and 
Catholic Relief, Save the Children. These are extraordinary 
private voluntary organizations that do remarkable work all 
around the world, and none of us would be able to achieve our 
objectives without these exceptional partners.
    I appreciate your making some reference to the mission I 
headed a few days ago. I led the humanitarian mission to the 
Darfur region of the Sudan, including all of the U.N. 
humanitarian agencies. My partner was Ambassador Vraalsen from 
Norway who had been the Norwegian Ambassador to the United 
States and is the Secretary General's Special Envoy to the 
Sudan. We spent time conferring with the leadership of the 
country and then spent 3 days in the field in Darfur. I led the 
team to west and north Darfur and Ambassador Vraalsen took the 
team to the south.
    I must report to you that this humanitarian crisis is of 
extraordinary seriousness. Today there are more than 1 million 
people displaced from their homes. They have been displaced in 
the most violent, mean-spirited way possible. Their homes have 
been burned. Their possessions have been taken. Their livestock 
has been stolen. The women have been raped. It would be hard to 
overstate how unpleasant this issue is.
    I then went for a couple of days on my own just in my WFP 
role to Chad where I visited camps of another 100,000 refugees, 
half registered, half have just congregated. The conditions 
these people are living in are tragic, sad. It would break your 
heart. I visited a camp in Mornei, 60,000 people in the camp, 
17,000 women, 9,000 men, and 34,000 children. Like most 
tragedies around the world, children are disproportionately 
affected and at risk.
    This is all complicated by the rainy season which is 
approaching. But the fundamental issue is the government's 
willingness to provide protection and security, to get the 
Janjaweed and marauding militia from the north under control. 
The cease-fire between the rebels in the south and the 
government is doing pretty well, but the government has the 
responsibility under the humanitarian cease-fire to look after 
and to control and manage the rebels from the north. And that 
is not happening.
    I must tell you that I have never in my life seen a group 
of people so frightened, people frightened to leave the camp, 
people frightened to go home.
    The rest of Sudan had a bumper agricultural crop this year, 
but the crop in the Darfur region was lost and the crop in the 
Darfur region will not be planted next year. So we will be 
sitting here a year from now with this same crisis on our 
hands. And the government's ability to get control of the 
rebels is the key.
    We are making progress on humanitarian access. Our folks 
reported that we are now feeding about 800,000 of the people at 
risk, but the issues of water and sanitation and shelter and 
health care--at the same camp, Medecin Sans Frontiere from 
France, just a few people providing all of the health care for 
the camp. Five weeks ago, a few hundred children under 5 
chronically malnourished; today, more than 2,000. So the 
humanitarian tragedy is enormous.
    I must pay tribute to Andrew Natsios and my colleagues at 
USAID for their extraordinary work in making it possible for 
the humanitarian community to respond. But this is an issue 
that is of great tragedy.
    When I left, I was asked by the media, Jim, is this most 
serious humanitarian crisis in the world today? Clearly, 1.2 
million, 1.3 million are at risk. By year end, it could be 
double that. And I said, this is a very serious problem. But in 
all candor, I have to report in my own view that the crisis of 
HIV, especially in sub-Saharan Africa, is the most 
extraordinary humanitarian crisis in the world today. You both 
correctly point out that more than 40 million people are 
infected. And 75 percent of them are in sub-Saharan Africa. 
Seven million farm workers have lost their lives. To put that 
in context, that is more than twice the entire on-the-farm 
population of the United States and Canada.
    An overwhelming burden on the health care system in Africa, 
a system that is almost nonexistent, but now overwhelmed by 
HIV/AIDS. The number of orphans, 14 million today, going to 20 
million. And 2.2 million people died in sub-Saharan Africa.
    The life expectancy in many parts of Africa has been 
absolutely cut in half. Years ago, the life expectancy in 
Zimbabwe was 67 years. Today it is 33. A staggering impact on a 
    Think about a country that has a population of 11 million 
to 12 million people. Thirty-five percent of the adults are 
infected with HIV. With 800,000 to 900,000 orphans. A 
dramatically deteriorated agricultural system. No foreign 
exchange. Tough weather issues. Challenges of governance. 
Dramatically diminished health care. Virtually dramatically 
diminished public finance system. Tens of thousands of 
households headed by children. It is not uncommon to see a 
little girl the size of my 8-year-old granddaughter, she is 15, 
listless, sick, sad, not educated, hungry playing mother and 
father to a family of five or six children. If it was a few, it 
would be one thing, but it is there by the hundreds of 
    The burden on the elderly, almost beyond comprehension. The 
7 million lives that have been lost in agriculture or the 2-
plus million that were lost are the most productive people. You 
will see a grandmother in her 70s, very slight, often looking 
after 20 or 30 children, and she has nothing.
    WHO would tell you that undernourishment is the most 
serious health problem in the world. The lack of 
micronutrients, a top 10 health problem, the lack of iodine, 
iron, vitamin A, zinc. You correctly state that 24,000 people 
die of issues related to hunger every day, 18,000 of them 
children. You need to know that they do not die in high profile 
crises. The world is focused today on the Sudan. It has been 
focused on Ethiopia. But 90 percent of people who die of 
hunger-related issues die off in the back woods on a dusty road 
somewhere totally unnoticed.
    It is easier for us to raise resources for high profile 
crises. Our great need is to have resources to address hunger 
and nutrition and now HIV/AIDS in places that do not make the 
headlines. AIDS has become the sinister element in hunger.
    If I could just, as I head into my comments, thank the 
United States. As an American, I have been overwhelmed the last 
2 years with the generosity of cash and resources and caring 
and brain power of USAID and the U.S. missions around the 
world. Last year the United States provided well over half our 
budget of a billion and a half dollars. The President's 
commitment, which Randy leads, to address AIDS is the single 
most important step forward that has happened in the history of 
this crisis. Eighty percent of the research for HIV comes from 
the National Institutes of Health in the United States.
    This committee should take time this year to celebrate the 
50th anniversary of Food for Peace started by President 
Eisenhower in 1954. This initiative now for 50 years has saved 
millions of lives and enhanced the lives of millions more.
    Food and nutrition, critically important. You correctly 
quote Peter Piot when he says, I go to a village in Malawi and 
talk about what are the needs of people infected with HIV, and 
the first thing they ask for is food.
    The burden on women is enormous. Women provide 80 percent 
of the agricultural production in sub-Saharan Africa. They now 
have close to 60 percent of the HIV infections, and they 
provide 100 percent of the care in the household. They ask for 
    I think it is always good advice to listen to the people 
who are most seriously affected by a crisis. They need food, 
but they also need water, clean water, and they need access to 
education. AIDS and hunger interact. AIDS dramatically 
undermines food production. The loss of 7 million agricultural 
workers, to say nothing of the 16 million on the horizon, and 
the debilitating effect AIDS has had on people still living and 
their inability to be productive. Malnourished bodies are more 
receptive to HIV and more receptive to the opportunistic 
diseases that follow.
    The exploitation of hungry, poor people is enormous. 
Poverty increases vulnerability to HIV. AIDS increases the risk 
of poverty.
    The stigma attached to all of this is enormous and it makes 
it much more difficult for us to target direct response to a 
person infected. We generally find ourselves responding to 
communities where we know there is a high rate of incidence.
    We are very focused on children and orphans, an 
unbelievable burden on children who have lost their parents to 
HIV. The psychological loss, much more likely to be 
malnourished, more vulnerable to abuse, more vulnerable to HIV 
themselves, less likely to go to school, and less likely to get 
health care if you are an orphan. Maybe the only thing worse 
than being an orphan is being the child of a parent who is 
dying of AIDS, to have that experience. The sacrifices of 
children for their parents in these circumstances are 
    I have talked about the impact on the elderly, on 
grandparents, on the extended family. Africa has a great 
tradition of the extended family taking care of kids at risk 
and orphans. But the burden of 14 million HIV orphans, together 
with 26 million more orphans in sub-Saharan Africa is becoming 
an overwhelming burden on the extended family.
    Food aid is critically important, and there has been a 
substantial decrease in food aid in the world in the last 
several years. But food aid is critical to feeding children, 
especially children in shelters and centers. Food aid is 
critical as an incentive to bring children in for vocational 
training. Food aid is critical to help provide support for 
foster families.
    We are very focused on children being enrolled in school. 
There are 820 million hungry people in the world, more than 300 
million hungry children. Half of them do not go to school. Most 
of those that do not go to school are girls. There is no 
substitute for the power of the investment of feeding a child 
to see that a child gets one good meal every day and using that 
as an incentive for that child to go to school. We know what it 
has meant to our own country. We know what it has meant to 
Japan and the rest of the world is no different.
    Education ultimately is the hope for addressing the HIV 
epidemic. Kids come to school. They have a chance for HIV 
education. More importantly, they have a chance to generally be 
educated and begin to have some sense of what their lives might 
be, to have more hope for their lives and who they might 
    And I cannot overstate the importance of this particular 
issue on young girls. A girl is fed, is incented to come to 
school. If she only comes for a few years for primary 
education, her life will never be the same. Her child-bearing 
habits are different. Her aspirations for her children are 
different. She will be a different kind of parent. She will be 
a different kind of citizen.
    When you think that we can feed a child in school for $35 a 
year and for 30 cents provide the medicine to get rid of the 
worms, there is no more powerful leveraged investment the world 
can make in the future for its children but for itself than 
providing food for kids to go to school. School feeding has 
enormous nutritional impact, and clearly reduces the 
vulnerability for HIV/AIDS.
    The McGovern-Dole school feeding program, which this 
Congress made possible, provided $300 million to feed 8 million 
school children in 2001. Today in 2004, you provided $50 
million and we are only able to feed 1 million school children. 
We have done a good job of encouraging the rest of the world to 
help us with this program. We have numerous countries helping 
us now, and my hope is that as you think about ways you can 
help us address the HIV issue, the orphans issue, that you will 
be focused on the McGovern-Dole school feeding program. Nothing 
more important than the well-being of children. The best chance 
we have to make progress on the HIV/AIDS issue is to educate 
children between the ages of 5 and 15 about the seriousness, 
the hazards, the dimensions of HIV, and that best occurs in the 
    Randy will talk in a few minutes, I am certain, about 
antiretroviral drugs. People in the United States, the NGO 
community, the pharmaceutical industry, all around the world 
have done a terrific job in bringing down the price, the cost 
of antiretroviral drugs, still not within the reach of very, 
very poor people, but more accessible than historically has 
been the case.
    Antiretroviral drugs [ARVs], medicine generally, only work 
in a well-nourished human being. For ARVs to work against HIV--
the same scenario applies to tuberculosis--a well-nourished 
body with access to clean water, a strong diet is key to making 
the ARV situation productive. We can feed a person who is 
vulnerable, who is going to take ARV for 29 cents a day. Many 
have said that adequate food and nutrition is the first line of 
defense in the fight against HIV. A person that has access to 
food and nutrition and water and antiretroviral drugs has a 
chance to get back on their feet and to have a prolonged life.
    I was in Haiti a few days ago, another tough, tough place, 
once again a place where the U.S. mission is playing quite a 
remarkable role. We have a great U.S. Ambassador there. But I 
had a lady I visited with, working in clinics. The highest HIV 
prevalence rate in the Western Hemisphere and the largest 
calorie deficit of any country in the world, by the way. But a 
lady said, you know, Mr. Morris, ``do I spend what I have to 
feed my children today or do I pay for drugs I need to stay 
alive for them tomorrow?'' A question none of us want to have 
to answer, but it is a question that lots of people are facing. 
And we know that at the end of the day, the poorest in the 
world will be the last to have access to antiretroviral drugs, 
and the most important investment we can make in them in the 
interim is access to food and good nutrition.
    I do not know what value we put on keeping someone alive, 
giving someone a few more days or a few more months with their 
children, but I suspect it is a very high value. So my message 
is that the HIV crisis, especially in Africa, especially in 
some countries in the deepest southern part of Africa, the 
issues are so extraordinarily difficult that it will be curious 
to know how these places will have a chance to survive and come 
out of this. They will have no chance without help from the 
rest of the world. Our investment in food and nutrition is at 
the base of getting rid of poverty. It is at the base of good 
health care. It is at the base of gender equity. It is at the 
base of universal primary education. It is at the base of 
solving infant mortality and addressing issues of maternal 
health. And it is absolutely the key issue in getting on top of 
the HIV crisis and all of the other health issues that stem 
from it.
    The World Food Program operates all over the world. We have 
special HIV programs in 40 countries, 30 countries in Africa, 
and we have special programs in 21 of the 25 most heavily 
affected countries in Africa. I should tell you that we have 
done all of this without financial incentive or encouragement 
from anyone in the world. We have done it because it is at the 
base of solving the problems of the hungriest and poorest 
people in the world.
    So I am grateful for this chance to tell this story. It is 
an enormously important story to humanity, but it is likely a 
story with the right focus and the right resources that we can, 
over time, get on top of. The United States has been 
extraordinarily generous, has set the pace. We have negotiated 
a new partnership with the Clinton Foundation last week to work 
in Tanzania and Mozambique and that is a good thing.
    But as is usually the case, the world will continue to rely 
on leadership from the United States to solve the toughest of 
problems, and this is clearly one of them.
    Thank you, sir.
    [The prepared statement of Mr. Morris follows:]

               Prepared Statement of Hon. James T. Morris

    Mr. Chairman. During the course of this hearing several hundred 
people will die from hunger. Most of the victims will be malnourished 
young children too weak to fight off disease. Their deaths will occur 
quietly in dusty villages in Malawi, the slums of Mumbai, the highlands 
of Peru. These deaths will not make the news.
    Hunger only captures the headlines at the height of crises caused 
by politics and natural disasters--the war in Iraq, the violence in 
Darfur, drought and civil conflict in Afghanistan. The fact is that 
only 8 percent of the deaths from hunger occur in these types of 
dramatic food emergencies. It is not that these operations are not 
urgent--and right now we face severe shortages in funds for Angola and 
the DPRK--but they are usually far better funded than efforts to combat 
chronic hunger.
    On average, 80 percent of the money donors give to the World Food 
Program is earmarked for high profile emergencies. There is no clearer 
confirmation of what people in the humanitarian community call the CNN 
effect--money follows the media. If there are no horrible images of 
skeletal babies, no food riots, no mass movements of starving people, 
the cameras are soon gone. And often, so is the money.
    Unfortunately, for over 800 million people, the struggle to find 
enough food goes on off camera. Hunger and hunger-related diseases 
still claim more lives than AIDS, tuberculosis and malaria combined.
    Of the 10 greatest threats to public health, my colleagues at WHO 
tell us that undernutrition is still number one and deficiencies in 
micronutrients like iron, iodine and vitamin A rank number eight. (WHO, 
2002) One in 4 of the world's children under 5 years old is 
underweight--168 million all told; 181 million are stunted from 
longterm undernutrition, and 51 million are wasted from short-term 
severe malnutrition. The life of a child is lost every 5 seconds 
because we have failed to end widespread hunger and malnutrition.
    Much of the silent suffering from hunger today is among millions of 
victims of AIDS and their families. AIDS has added a new, more sinister 
element to the dynamics of hunger. I have been asked to give you an 
overview of global food issues and then focus in on the lethal 
connection between the AIDS pandemic and the growing incidence of 
chronic hunger in developing countries, especially in Africa.
    Before getting into the main portion of my testimony, I must point 
out that the United States has been--and continues to be--extremely 
generous to the World Food Program. The US provided nearly $1.5 billion 
to WFP last year, once again ranking as the top donor.
    WFP has also been working closely with our other top traditional 
donors around the world to increase contributions, while we are 
aggressively pursuing donations from more non-traditional donor states 
as well as individuals throughout the world.
    The struggle for resources is ongoing--and one that we share with 
USAID, NGOs and others who are working to reduce hunger and poverty 
around the world.
                            hunger and aids
    Mr. Chairman, we are in danger of falling even farther behind in 
the battle to end hunger unless we come to grips with the interaction 
between hunger and the AIDS epidemic in the developing world. We tend 
to see AIDS through the lens of our own experience here in the United 
States, while the economic and sociological dynamics are very different 
in Mozambique, Cambodia, or Zimbabwe.
    The AIDS coverage in the media focuses heavily on the demand for 
anti-retroviral drugs, but if you were to go out and talk to families 
in southern Africa, the hardest hit region, you would get a very 
different picture. These people talk about food.
    My good friend Peter Piot, head of UNAIDS, often relates a story 
about one of his first visits to Africa: ``I was in Malawi and I met 
with a group of women living with HIV. As I always do, I asked them 
what their highest priority was. Their answer was clear and unanimous: 
food. Not care, not drugs for treatment, not relief from stigma, but 
    Is that so surprising? My colleagues at FAO calculate that 7 
million farmers have been lost to AIDS in Africa alone, the continent 
with the worst food security problems in the world. Eight out of 10 
farmers in Africa are women, mostly subsistence farmers, and women are 
disproportionately affected by the disease.
    So my first message on AIDS to the Congress is simple--let's start 
listening to people living with this horrible disease. As Randy 
Tobias--a close friend for decades--shapes President Bush's great 
initiative I know he will listen. Ending AIDS is not a battle we will 
win with medicine alone--we need proper nutrition, education, clean 
water. We need integrated packages of assistance or we run the risk of 
tossing our money away.
    AIDS and hunger interact. They feed off one another. Why is food 
such a big issue for the families affected by them?
     First, the disease is seriously undermining food 
production. With millions fewer farmers working, there is less food. 
Weakened HIV-positive farmers who can still work are not as productive 
and less capable of earning off-farm income as well. As farmers earn 
less, they cannot afford fertilizers and other farm inputs. Harvests 
dwindle further and they enter a downward spiral, selling what assets 
they have and sliding into abject poverty. Soon enough, their families 
go hungry.
     Then there is the nutritional dimension. Malnourished 
bodies are more prone to disease, including AIDS. People who are both 
HIV positive and malnourished are especially susceptible to 
opportunistic infections, most notably tuberculosis.
     Hungry people are also more vulnerable to exploitation. 
Prostitution is especially rampant in poor communities where people 
simply do not know where they will get their next meal. Poverty-
stricken families look the other way as uneducated girls earn money in 
one of the few ways they can.
    There is a vicious cycle at work here. Poverty increases 
vulnerability to HIV infection. AIDS increases the risks of poverty. 
But for communities seeking to find their way out of the cycle the way 
forward is anything but clear. For one thing, the stigma of AIDS 
discourages testing and we usually do not know who is HIV positive and 
who is not. So successful interventions must often target whole 
communities where we know the disease is taking its heaviest toll.
    There are three specific ways WFP and our NGO and government 
partners can intervene to help:
    First, we must do everything that we can do TODAY to meet the needs 
of the orphans and vulnerable children--in particular those in the most 
affected communities.
    The number of orphans in sub-Saharan Africa is huge, growing and 
likely to continue to grow. By 2010, some 20 million children will have 
lost one or both of their parents to AIDS.
    Combined with other causes--including war and other diseases--the 
total number of orphans is an almost incomprehensible 40 million young 
people. That may seem a large burden for the world to bear. The real 
burden is borne by the families and communities on the frontline of the 
epidemic. And by the children themselves.
    In addition to their deep psychological loss, orphans between 10 
and 15 years old are subject to higher rates of malnutrition, physical 
and sexual abuse, and exposure to HIV. And they are much less likely 
than children whose parents are alive and well to go to school or get 
health care.
    These are brutal facts. But one even more jolting is that as bad 
off as orphans are, many children whose parents are sick with AIDS can 
be even worse off. They must watch their parents die, grow poor as the 
household's income dwindles, and deal with the trauma of rejection as 
neighbors--even some family members--shun them.
    These kids are the ones who shoulder the real burden of the 
pandemic. They are sacrificing their childhoods and futures to nurse 
sick parents and earning money for their families' survival. AIDS has 
turned a generation of children into parents--especially in Africa. It 
is not unusual to see a 10 or 12-year old raising siblings without the 
guidance of an adult.
    Once orphaned, millions of children are shifted from household to 
household--and sometimes from household to the street. It is the 
elderly of Africa, especially women, whose backs are further bent under 
the weight of providing these children with food, shelter and--in the 
very best of circumstances--a school uniform and fees so they can 
resume their education.
    Food aid has an important role to play in helping families and 
communities in supporting orphans and vulnerable children. For example, 
we use food aid to:

   directly feed children in shelters and centers;

   support vocational training programs;

   make sure that foster parents--including grandmothers who 
        are sometimes looking after a dozen of their grandchildren--can 
        feed them all; and

   bolster the family larder with take home rations so kids can 
        be kids and go to school instead of working the fields or 
        running off to the nearest city.

    Right now, we are only scratching the surface. We can do so much 
    Second, we must do everything we can to help children in the most 
affected communities and countries enroll in school--and attend 
    There is such strong agreement that education is our most immediate 
hope for addressing this epidemic. When it comes to HIV prevention, 
it's been called the ``education vaccine''. I'm not just referring to 
HIV prevention education, as important as that is. I'm talking about 
something much more powerful than that--the skills and social norms 
that we learn in a safe and nurturing school environment. It can shape 
who we are, how we relate to others, and what we are able to do with 
our lives--for ourselves and others.
    Helping children to attend school longer--especially girls--has a 
proven record for interrupting the spread of HIV. The longer a girl 
attends school the more knowledgeable she becomes. Knowledge is power 
and it's that personal power that enables young people to better manage 
the circumstances around them and better judge the actions of others. 
This translates into positive and healthy behaviors that last a 
    Mr. Chairman, food aid has an important role to play in 
strengthening schools, particularly in those communities most affected 
by AIDS.
     We know that one nutritious meal a day at school can 
improve enrolment, attendance and academic performance--we have seen 
enrolment climb up to 300 percent in schools that provide meals.
     We know that where school-feeding programs involve the 
community, schools become platforms for AIDS awareness and HIV 
prevention, health and nutrition education, agriculture and skills 
     And we know that take-home rations for the most vulnerable 
children can offset the family's cost of sending them to school--a 
major issue in families where the breadwinner has AIDS.
    School feeding both mitigates the nutritional impact the epidemic 
has directly or indirectly on children and also helps reduce their 
vulnerability to HIV infection by promoting education. It stands out as 
one of the few interventions which we can effectively target at 
communities with high HIV rates--and scale up rapidly.
    I am concerned that funding for school feeding has dropped off. The 
US has always been a generous contributor and we need other countries 
to do more as well. In 2001, $300 million in USDA funds were allocated 
to school feeding under the McGovern-Dole initiative and in the FY 2004 
budget the figure fell to $50 million. With the $300 million we had in 
2001, nearly 8 million children were being fed in school in countries 
like Afghanistan, Nicaragua, and Kenya by WFP and our NGO friends. 
Barely 1 million will now be receiving help from this worthwhile 
    Knowing what we do about the benefits, this Congress should 
actively support a drive to extend school feeding to every school in 
every community currently most affected by the epidemic.
    Congress should also look at funding a full package of assistance 
needed by hungry, poor people. That is to say--food, water, medicine 
and shelter are all needed together. All humanitarian organizations, 
from WFP to UNICEF to our PVO partners, require this full package of 
assistance to appropriately address the needs of the most vulnerable.
    Third, Mr. Chairman, we must do all we can to use food and 
nutritional assistance to maximize the benefits of therapeutic drugs 
for AIDS and related conditions.
    Medicine only fully works its magic, however, on a well-nourished 
person who has access to clean water and good diet. In short, those 
living with HIV/AIDS need food, water and medicine.
    Leading nutritionists throughout the world tell us that adequate 
nutrition is the first line of defense in the battle against HIV/AIDS. 
We also know that the populations that are the poorest and most food 
insecure, and currently receiving food aid, are not always the same 
populations who are infected and affected by HIV/AIDS.
    Therefore, WFP and our PVO partners need ADDITIONAL RESOURCES to 
help feed this highly vulnerable population. In short, we are already 
stretched thin by dozens of emergencies around the world--from Haiti to 
Sudan--yet we are serving only 10% of the world's hungry population. We 
need more resources to expand our efforts to fight the HIV/AIDS 
pandemic. We cannot reprogram our limited resources that are already 
deployed around the world to the poorest, most vulnerable areas.
    Anti-retroviral drugs can work wonders. So can medications to treat 
the most common opportunistic infection, tuberculosis. In hard hit 
communities, these drugs can help put sick people back on their feet 
    Food and nutrition programs have a vital support role to play here. 
AIDS is no different from any other disease when it comes to one basic 
fact--our bodies need good nutrition to fight off infection, regain 
strength and live productively.
    Good nutrition can help to make AIDS and TB drugs work their 
miracles. Especially in symptomatic periods where caloric requirements 
are greater and capacities to work compromised, food and nutritional 
support can be critical. In countries like Cambodia, Lesotho and 
Uganda, WFP has successfully used food rations as an incentive to keep 
TB patients coming back for the full course of drug treatment which 
helps prevent mutations that cause everyone concern, even here in the 
United States.
    Last month, I was in Haiti visiting our operations there. The 
island is the worst hit by AIDS in the entire hemisphere and 
tuberculosis is widespread. I heard a saying Haitians use about TB I 
found fascinating. ``Giving a TB patient medicine with no food is like 
washing your hands and drying them in the dirt.'' It's a point we might 
well remember as we grapple with AIDS.
    I don't think any one of us could think of a worse choice than one 
that faces so many parents with AIDS--``Do I spend what I have to feed 
my children today or pay for the drug therapies I need to stay alive 
for them tomorrow?'' Imagine that kind of choice in your life.
    The World Health Organization, UNAIDS, the world's pharmaceutical 
companies, private foundations, activists and governments are now doing 
a tremendous job of reducing the cost of AIDS drugs for the poor.
    But now, after having taken the bold leap to help the poorest with 
ARVs, why would we not want to get the most out of those investments? 
Why would we not ensure adequate nutrition for those receiving ARVs to 
strengthen their bodies as they fight the disease? Why wouldn't we 
ensure the food-security of their families while they regain their 
    Sadly, for many, anti-retroviral drugs will come too late or not at 
all. Even under the most hopeful scenarios, millions of people won't 
have access to them soon. I'm talking about poor people who live in 
communities with no clean water and no health clinic. Rural villages 
and poor subsistence farmers may well be last in line once ARV 
therapies are more widely available and that will further damage 
    Mr. Chairman, when it comes to humanitarian aid, governments don't 
lead, they follow. Already there are thousands of community and faith-
based organizations out there working in the greatest humanitarian 
tradition, easing the suffering from AIDs and hunger. Before closing 
I'd like to give you just one example.
    There is an NGO that WFP works with in Uganda--the National 
Community of Women Living with AIDS. One of our beneficiaries is Yudaya 
Nazziwa, a forty-one year old widow. Yudaya is preparing to die. She 
has AIDS and each day she writes into a journal something of her family 
history and practical advice for her oldest daughter. The Ugandans call 
these journals ``Memory Books''. Her tale is painful, but sadly, it is 
not unusual--her husband died of AIDS and his relatives took over her 
comfortable home and possessions. She and her four children now live in 
a slum and depend on WFP food aid to survive. Yudaya is tough and wants 
to hang on as long as she can--to work if possible and pass on what she 
knows to her children. Food aid is keeping her nourished, helping her 
fight off diseases. As she puts it: ``Now I have to eat for two--for 
myself and the virus.'' Maybe one day--let's hope soon--Yudaya will be 
on anti-retroviral drugs. President Bush's massive multi-billion dollar 
campaign headed by my good friend Andrew Tobias, holds out that hope. 
But for today, food aid is helping keep people like Yudaya alive and 
even if she does get medication soon, we all know that a well nourished 
patient stands a better chance of survival.
    I want to add one more chapter to the Memory Books of these Ugandan 
women--a chapter about how we all helped keep them alive and their 
families together.
    This is the greatest humanitarian challenge of our time. I am so 
deeply proud that President Bush has made the enormous commitment he 
has and called on talented people like Randy Tobias and Andrew Natsios 
to take this challenge on. All of us at the World Food Program are 
ready to give it all we've got to help.
    The work is not done out there. We can and we should do more for 
the 800 million people going to bed hungry every night. I know the US 
Congress has limited choices with fewer dollars available. But, working 
together--with the White House, with Congress, and with USAID, with 
USDA, with the State Department, with our private, voluntary partners, 
and with generous everyday Americans, we can make a difference.

                          World Food Programme

            The Food Aid Organization of the United Nations

News Release--11 May 2004


    Washington, DC.--James Morris, the Executive Director of the United 
Nations World Food Program (WFP), today testified before Congress on 
the growing hunger problem around the world and how it is exacerbated 
by the AIDS crisis.
    More than 40 million people are infected with HIV and some two-
thirds of them live in conditions of severe poverty in sub-Saharan 
Africa. Morris highlighted to Congress the critical role that food aid 
plays in helping people living with HIV/AIDS fight the disease.
    ``Ending AIDS is not a battle we will win with. medicine alone--we 
need proper nutrition, education, and clean water,'' Morris told the 
Senate Foreign Relations Committee. ``The AIDS coverage in the media 
focuses heavily on the demand for anti-retroviral drugs, but if you 
were to go out and talk to families in southern Africa, the hardest hit 
region, you would get a very different picture. These people talk 
    People need good nutrition to fight off infection, regain strength 
and live productively. Malnutrition breaks down people's immune 
systems, and makes them more prone to disease, including AIDS.
    Morris also appealed to Congress to put a greater priority on funds 
for people suffering from chronic hunger, rather than just on the 
victims of high-profile disasters and emergencies.
    ``During the course of this hearing several hundred people will die 
from hunger,'' Morris told Congress. ``Most of the victims will be 
malnourished young children too weak to fight off the disease. Their 
deaths will occur quietly in dusty villages in Malawi, the slums of 
Mumbai, the highlands of Peru. These deaths will not make the news.''
    Every five seconds, a child dies from hunger-related diseases, and 
malnutrition is still the number one public health threat around the 
world. More people die from hunger-related causes than from AIDS, 
tuberculosis and malaria combined.
    The US government has been the top donor to WFP since its inception 
in 1963 and continues to be the agency's most generous contributor. 
Last year, the US government donated nearly US$1.5 billion for feeding 
programs in countries ranging from Afghanistan to Iraq to Zambia.
    Currently, more than 800 million people are chronically hungry, a 
figure which increased by 18 million in the second half of the 1990s. 
One in four of the world's children under five years old is 
underweight--168 million all told. At the same time, WFP is facing a 
shortfall in 2004 of 1.8 million metric tons of food or $1 billion for 
critical operations in 2004.
    Morris also recommended that Congress provide more food assistance 
to AIDS orphans--expected to rise to 20 million children by 2010--and 
increase school feeding programs. WFP provides nutritious school meals 
to children in 69 countries to attract them to school, increase 
retention rates and improve learning ability.
    ``Helping children attend school longer--especially girls--has a 
proven record for interrupting the spread of HIV,'' said Morris. ``The 
longer a girl attends school, the more knowledgeable she becomes. This 
translates into positive and healthy behaviors that last a lifetime.''
    In his testimony, Morris noted his concerns about the growing 
humanitarian crisis in the Darfur region of western Sudan, which has 
led to more than one million people being displaced from their homes 
and more than 100,000 refugees fleeing to Chad. Morris led a high-level 
UN inter-agency assessment mission to Darfur and Chad at the end of 
    ``What we witnessed throughout Darfur and in neighboring Chad is a 
dramatic humanitarian crisis, no doubt one of the worst in the world 
today. It is a crisis of massive displacement, critical humanitarian 
needs and extreme levels of violence and fear,'' said Morris.

                              *    *    *

    WFP is the world's largest humanitarian agency: in 2003 we gave 
food aid to a record 104 million people in 81 countries, including 56 
million hungry children.
    WFP Global School Feeding Campaign--For just US$19 cents a day, you 
can help WFP give children in poor countries a healthy meal at school--
a gift of hope for a brighter future.
    Visit our website: www.wfb.org

    The Chairman. Thank you very much, Mr. Morris, for that 
very compelling testimony.
    I want to introduce now the Honorable Randall Tobias, 
Global AIDS Coordinator, Department of State, Washington, DC. 
Mr. Tobias, would you proceed.

                    U.S. DEPARTMENT OF STATE

    Ambassador Tobias. Mr. Chairman, thank you and thanks to 
the members of this committee for the opportunity today to talk 
about the very important relationship between the global HIV/
AIDS pandemic and hunger.
    I am particularly pleased to appear this morning with my 
U.S. Government partner in this effort, Andrew Natsios, and my 
longtime friend, in fact, my friend for almost 43 years, Jim 
Morris, the Executive Director of the World Food Program.
    Mr. Chairman, I appear before you today, 7 months after my 
confirmation hearing, my last appearance before this full 
committee. Since that time, I have had the opportunity to visit 
many of the countries in which we are focusing our efforts, 
including South Africa, Uganda, Kenya, Botswana, Zambia, 
Namibia, Rwanda, Ethiopia, and Mozambique, and I will be 
leaving in the days ahead for a visit that will include 
Nigeria, Cote d'Ivoire, and Tanzania.
    I am pleased to report that in those 7 months, I think we 
have made historic progress in beginning to achieve, the 
President's, the Congress', and the American public's goal of 
bringing prevention, treatment, and care to millions of adults 
and children who are courageously living with HIV/AIDS, and 
these efforts are replacing despair with hope.
    Early this year, I submitted to you and to other 
appropriate congressional committees a comprehensive 5-year 
strategy to implement the President's Emergency Plan for AIDS 
Relief. The strategy is guiding our efforts to rapidly expand 
prevention, treatment, and care, to identify new partners, to 
build capacity for long-term success, and to amplify the 
worldwide response of HIV/AIDS by working with other partners.
    Let me also note that in February, less than a month after 
Congress appropriated funds for the first year of the 
President's Emergency Plan, I announced $350 million in 
initial, first-round awards to service providers, NGOs and 
others who are bringing relief to suffering people in some of 
the countries hardest hit by the HIV/AIDS pandemic. These 
awards are already rapidly scaling up programs that provide 
antiretroviral treatment, prevention programs, including those 
targeted at youth, safe medical practices programs, and 
programs to provide care for orphans and vulnerable children.
    With just this first round of funds, an additional 50,000 
people living with HIV/AIDS in the 14 focus countries of the 
Emergency Plan will begin to receive antiretroviral treatment 
which will nearly double the number of people who are currently 
receiving treatment in sub-Saharan Africa. Today activities 
have been approved for antiretroviral treatment in Kenya, 
Nigeria, and Zambia, and patients are receiving treatment in 
South Africa and Uganda because of the Emergency Plan.
    In addition, prevention through abstinence messages will 
reach about 500,000 additional young people in the plan's 14 
focus countries in Africa and the Caribbean through programs 
like those of World Relief and the American Red Cross' Together 
We Can program.
    The first release of funding from the President's plan will 
also provide resources to assist in the care of about 60,000 
additional orphans in the plan's 14 focus countries. Care will 
include providing critical basic social services and scaling up 
basic community care packages of preventive treatment and safe 
water, as well as HIV/AIDS prevention education.
    This is only the beginning of our efforts. Later this week 
or early next week, Mr. Chairman, we will be providing this 
committee and other congressional committees with the required 
notification for the obligation of approximately an additional 
$300 million which will be our next tranche of funding. I seek 
your support in ensuring that we are able to move these 
resources as quickly as possible so we can continue to respond 
with urgency that these individuals so require.
    As we make additional awards, the numbers of persons 
receiving treatment and care will increase substantially. I 
also expect an increase in our efforts to strengthen and expand 
safe blood transfusion and safe medical injection programs, as 
well as our efforts to strengthen human and organizational 
capacity through health care twinning and volunteers.
    The President's Emergency Plan has three clear goals to be 
achieved over the next 5 years in 14 countries in sub-Saharan 
Africa and the Caribbean: first, as you know, it is to treat 2 
million HIV-infected people with antiretroviral therapy; 
second, to prevent 7 million new infections through increased 
HIV testing and through behavior change; and third, to provide 
care for 10 million HIV-infected individuals and the children 
that Jim has mentioned who have been so devastated by this 
pandemic. This comprehensive and unparalleled approach through 
integrated treatment, prevention, and care is essential if we 
are to be successful, as we must be, in this global fight 
against HIV/AIDS.
    But, Mr. Chairman, as important as all of this is, clearly 
this program, the President's Emergency Plan, is not the whole 
answer. The President's initiative is intended to be part, but 
only part, of the potential solution to a very complex and 
multifaceted set of issues surrounding HIV/AIDS. This is a 
global pandemic that requires resources well beyond the scope 
of the President's Emergency Plan, resources focused on 
additional aspects of human need.
    The President's Emergency Plan is largely a health care-
based program focused on prevention, treatment, and care. It 
does not directly address hunger, but as you and others have 
correctly suggested, hunger and nutrition and a wide range of 
other issues are clearly linked to successfully addressing HIV/
AIDS. We recognize that food security, good nutrition, and 
clean water are inextricably linked to successfully fighting 
AIDS. Without access to safe and adequate food, people are less 
able to effectively respond to AIDS treatment.
    Moreover, drug resistance grows if people fail to stay with 
their treatment regimens. Persons living with HIV/AIDS but 
without access to sufficient food have less time to focus on 
care, and they pay less attention to issues of prevention. At 
the same time, we know that HIV/AIDS exacerbates food 
insecurity, production shortages, and long-term agricultural 
knowledge loss.
    To succeed in this battle, we must recognize the important 
relationships between hunger and HIV/AIDS, and we must work 
together in every way we can within our own government, as well 
as with other partners, including other governments, 
international organizations, the private sector, and 
nongovernmental organizations, to tackle this problem and turn 
the tide against HIV/AIDS. We must find every possible way to 
coordinate our efforts with those of other programs that bring 
resources to address hunger and the other related issues.
    One of the most socially and economically destructive 
aspects of HIV/AIDS is that it predominantly affects the most 
productive members of society, those between the ages of 15 and 
45. This directly impacts the size and the productivity of the 
labor force, with negative outcomes for family income, assets 
and agricultural knowledge and productivity. As has been 
mentioned, 7 million agricultural workers have already died of 
AIDS in Africa.
    The World Health Organization has estimated agricultural 
productivity losses from AIDS at the village and household 
level at anywhere from 10 to 50 percent in a selection of sub-
Saharan African countries. In fact, a UNAIDS assessment in 
Zambia showed that families in which the head of household was 
chronically ill planted an astonishing 53 percent less than was 
planted by households with a healthy head of household. 
Families that lose their most productive members and are forced 
to rely on the elderly or the young often resort to the sale of 
livestock or the sale of other assets to pay for food, as well 
as treatment or even funerals.
    The short-term consequences of this devastation is often 
food supply shortages which further lower agricultural 
productivity and so it goes. But the problem is not only the 
short term. Over time, agricultural techniques and knowledge 
are lost potentially further reducing crop yields and overall 
agricultural output in communities for extended periods of 
time. Therefore, the better methods of transferring 
agricultural knowledge between generations and better 
agricultural techniques that are less labor-intensive are 
needed to address the impact of HIV/AIDS on hunger and food 
    But, Mr. Chairman, this is merely one side of the equation. 
The other side is hunger's adverse impact on HIV/AIDS.
    We know that adequate nutrition and food bolster the immune 
system and allow people living with the virus to continue to be 
productive members of society. In combination with the care and 
the antiretroviral treatments that the President's Emergency 
Plan will bring to millions of people, farmers can continue to 
produce food, children can continue to attend school, and 
parents can continue to provide for their families. I saw this 
myself recently in Uganda when I visited a program funded by 
the U.S. Government in a rural area in the Tororo District in 
which we are already providing antiretroviral medicines to poor 
    In the face of hunger and inadequate nutrition, however, 
the disease will accelerate, expose the infected to new 
illnesses, and reduce their ability to respond to treatment and 
antiretroviral therapies. Hunger can also reduce the amount of 
time families and others can realistically dedicate to care and 
it may force people into activities that undermine our 
prevention efforts. For example, people suffering from hunger 
often migrate in search of emergency food relief or for 
employment, a trend that exacerbates the spread of HIV into new 
and possibly less-affected communities. Some evidence from some 
countries suggests that hunger drives women and young girls 
into prostitution to compensate for the lost income of a 
deceased family member.
    The linkages between hunger and HIV/AIDS will require the 
coordinated attention of many domestic and international 
    Recognizing that HIV/AIDS is a global emergency, I intend, 
with your support, to rapidly mobilize resources to prevent the 
momentum of increasing HIV/AIDS infections and stem the 
suffering through treatment and care. The focus of the 
President's Emergency Plan is on achieving those targeted goals 
within prevention, treatment, and care, and Congress' 
commitment to this initiative, through its authorization and 
appropriation of resources, is essential to its success.
    And while we maintain our focus on the task at hand, we 
recognize the complexity of the crisis and that addressing 
other issues, such as hunger and food security, are absolutely 
vital in the success of this total effort. It is crucial, 
therefore, that we in the HIV/AIDS field recognize the 
importance of coordinating with those who are addressing hunger 
and nutrition, as well as other issues like gender 
discrimination and economic development, to achieve success in 
the fight against the epidemic.
    Toward that end, I look forward to working with other U.S. 
Government agencies such as the Department of Agriculture, 
Health and Human Services, and the Agency for International 
Development to ensure that our food aid and HIV/AIDS efforts 
are mutually reinforcing. And I also look forward to 
strengthening our relationships with our international partners 
like the World Food Program and UNAIDS and the Global Fund to 
Fight AIDS, Tuberculosis, and Malaria, as well as with the 
World Health Organization.
    In fact, I want to take this opportunity this morning to 
commend Jim and the World Food Program for their recently 
expanded focus on HIV/AIDS in southern Africa as a clear 
example of the type of increased response to which we aspire. 
Under Jim Morris' leadership, beginning last month the World 
Food Program began adding nutritious food baskets to help those 
living with HIV/AIDS. The World Food Program is integrating 
HIV/AIDS prevention programs into its school feeding programs 
and it spent nearly $200 million on HIV/AIDS programs in 2002 
alone. This is exactly the kind of sustained, coordinated 
effort that we need.
    Mr. Chairman, thank you and thanks to the members of this 
committee for the opportunity to share my views on the 
relationship between HIV/AIDS and hunger and to update you 
briefly on our progress in implementing the President's 
Emergency Plan. I am grateful to you for your resolve in 
defeating this pandemic. Your leadership and support has 
facilitated the speed with which we are responding to people in 
need and that commitment will help ensure our success, success 
that over time will be measured in lives saved and families 
held intact and nations continuing to move forward with 
    Thank you very much.
    The Chairman. Thank you very much, Ambassador Tobias. Thank 
you especially for illustrating the strong cooperation between 
your agency and the Department of State, the United Nations, 
and the World Food Program. You have illustrated the 
interdependence well.
    I would now like to introduce the Honorable Andrew Natsios, 
Administrator, United States Agency for International 
Development from Washington, DC, a good friend of our 
committee. We welcome you. Please proceed.


    Mr. Natsios. Thank you, Mr. Chairman, members of the 
committee. Good morning. I am pleased to be with you, along 
with my good friends, Ambassador Randy Tobias and Jim Morris of 
WFP, to discuss the relationship between AIDS and hunger.
    I do want to testify to the leadership that Jim Morris has 
brought to WFP and not just in HIV/AIDS, but in emergencies 
around the world. We are a very close cooperating supporter of 
WFP. He and I talk often, and he led the team into Darfur, a 
major focus of USAID right now because a famine is brewing. It 
has not taken place yet, but we want to avoid it happening. 
Randy Tobias' leadership in the fight against HIV/AIDS is of 
critical importance to the U.S. Government.
    USAID has long been a leader in fighting both the HIV/AIDS 
pandemic, going back actually to the mid-1980s, even though it 
had a very small budget then, and in preventing hunger and food 
insecurity. I am pleased to report that with USAID's funding we 
are providing food aid resources for food, prevention 
education, care, and support to over 700,000 people in African 
communities that are the focus countries of the President's 
Emergency Plan for AIDS Relief. In addition, we have 
prevention, care, and treatment programs for HIV/AIDS across 
the continent, which of course is the area of the world most 
severely affected by AIDS. Seventy-five percent of the people 
who are HIV/AIDS-positive in the world live in sub-Saharan 
    The world has recently come to see how deeply these two 
problems are intertwined. We have a research paper \1\ that is 
at the back of the room here on the table that was done with 
one of our partner organizations, the Academy for Educational 
Development, and USAID on the effect of poor nutrition on the 
development of AIDS, which is quite useful I think from a 
clinical standpoint.
    \1\ The research paper referred to can be found on page 24.
    The majority of the world's hungry and food insecure live, 
unfortunately, where HIV/AIDS is also highest in terms of 
prevalence, and that is in sub-Saharan Africa. HIV/AIDS and 
food insecurity are a devastating combination.
    On June 1, 2001, almost 3 years ago, I issued my first 
cable,\2\ having just been sworn in as USAID Administrator on 
May 1, 2001, to our field missions asking them to not just have 
a health response to the AIDS pandemic but an integrated 
response that affects and integrates all our funding streams 
and all our programs in response to this catastrophic epidemic.
    \2\ The cable Mr. Natsios refers to can be found on page 32.
    In many villages across Africa, HIV/AIDS has wreaked havoc 
on food production, as Randy just mentioned. When someone is 
debilitated by disease, the food security of his or her family 
is in clear jeopardy. All too often families are forced to sell 
livestock and valuable assets to care for the sick or to pay 
funeral expenses. This then compromises any future earning 
    For people living with AIDS, good nutrition is essential 
for continued good health. It can also slow down or speed up 
the onset of the actual manifestation of the disease, depending 
on their nutritional circumstance. For too many people living 
with AIDS, getting enough to eat adds enormously to life's 
daily challenges.
    We do know in the last decade that chronic malnutrition has 
increased significantly in sub-Saharan Africa and we know that 
the AIDS pandemic is exacerbating this problem.
    The United States has a long history of support for food 
programs and has recently made an unprecedented commitment to 
fighting the AIDS pandemic. This year marks the 50th 
anniversary of the creation or the passage of what we call 
Public Law 480, which created the U.S. Food Aid Program. We are 
going to have a big celebration later this year.
    Since the inception of this program, the U.S. Government 
has provided 100 million metric tons of food aid valued at $33 
billion and has affected the lives of over 3 billion people in 
150 countries. Last year, the United States provided through my 
agency almost $1.1 billion of food aid to the World Food 
Program for their worldwide programs. The rest of our food 
budget goes to the NGO community. The vast majority of this 
goes through the Office of Food for Peace in USAID, which 
includes $6 million we send to WFP for their administrative 
expenses for emergency programs.
    The Bush administration has provided unprecedented support 
for the fight against HIV/AIDS through the President's 
Emergency Plan for AIDS Relief. USAID is helping fight the 
pandemic from a health perspective, as well as through our 
agriculture, education, and food aid programs. In fact, I 
mentioned earlier this cable that was sent out. We now have 3 
years of experience in how to integrate these programs 
    The Office for Food for Peace in USAID has invested $17 
million for 40,000 metric tons of food through NGOs for the 
most part to almost 700,000 HIV/AIDS infected children and 
adults in Haiti, Ethiopia, Kenya, Mozambique, Rwanda, South 
Africa, Uganda, and Zambia. We are doing grants to treat HIV/
AIDS and to prevent HIV/AIDS and to care for people with HIV/
AIDS simultaneously to the same NGOs and the same community-
based organizations in the same regions. This allows for more 
integration of these three functions together.
    One of the families we support is that of Pascasie Mukamana 
who is an orphan. She lives in Rwanda and she cares for her two 
sisters, one of whom is HIV-positive. With our funding, 
Catholic Relief Services provides a monthly food ration to her 
and her sisters.
    In addition to responding to the AIDS pandemic and to food 
emergency, USAID is addressing the long-term consequences of 
food insecurity. Through the President's Initiative to End 
Hunger in Africa, we are working toward fulfilling the 
Millennium Challenge goal of halving the number of hungry 
Africans by 2015. We are doing this, of course, through 
sustainable agricultural growth and efforts to augment rural 
family incomes, which usually means agriculture in sub-Saharan 
Africa. We believe, over the longer term, the best way to deal 
with food insecurity in Africa is for Africans to grow their 
own food.
    Through USAID's Harvest Plus Program, researchers are 
developing new varieties of wheat, rice, maize, and cassava to 
enhance the nutrient content, quality, and yield of these 
important staple crops. What we are doing is breeding into, 
working with the World Bank subsidiary, the CGIAR network of 
agricultural research stations, different micronutrients into 
different food crops where there is evidence that in the normal 
diet of these people, there is a micronutrient deficiency.
    Just one example of this, there is a serious problem with 
vitamin A deficiency in the Mozambiquean diet, which is why 
there is high child mortality rates. So what we did is we 
introduced a regular sweet potato, not an improved variety, 
which is very high in vitamin A--into the food chain. We taught 
people, women particularly, how to cook this and how to grow 
it. Using 125 community-based organizations, we introduced this 
crop into Mozambique. It has now taken off and it is part of 
the agricultural system of Mozambique. Through the agricultural 
system, not through vitamin supplements, we are actually 
getting vitamin A now into the Mozambiquean diet working with 
the Ministry of Agriculture in that country.
    HIV/AIDS also, unfortunately, is heavily prevalent. I think 
there is an 18 percent prevalence rate in Mozambique. So you 
see, by combining agricultural programs with the nutrition 
programs and with HIV/AIDS programs, you can, in an integrated 
fashion, address the pandemic.
    We are in a unique position because of our integrated 
programming at the mission level. Three-quarters of our staff 
at USAID are in the field, not in Washington. We have a highly 
decentralized program. I leave it to our mission directors as 
to how to do this technically. But by building on these 
strengths, we can ensure that assistance gets to the neediest 
in a timely and transparent fashion.
    Without the World Food Program, I want to add, as the 
wholesaler, in terms of doing the massive requirements needed 
both for development food but also particularly for emergency 
food, we could not function. Without the World Food Program, we 
could not be doing what we are doing now in Darfur province, 
for example, which is in terms of emergencies, the worst in the 
world, apart from the AIDS pandemic itself.
    Thank you for allowing us to testify today.
    [The prepared statement of Mr. Natsios follows:]

              Prepared Statement of Hon. Andrew S. Natsios

    Mr. Chairman, members of the Committee.
    Good morning. I am pleased to be with you, along with Ambassador 
Randy Tobias and Jim Morris, to discuss the relationship between AIDS 
and hunger. The U.S. Agency for International Development has long been 
a leader in both fighting the AIDS pandemic and in preventing hunger 
and food insecurity. The world has recently come to see how deeply 
these two problems are intertwined. The majority of the world's hungry 
and food insecure live where HIV prevalence is highest--in sub-Saharan 
Africa, where HIV and food insecurity are a devastating combination.
    I am pleased to report that with USAID's funding, we are providing 
food aid to 700,000 people in African communities heavily impacted by 
HIV/AIDS. In addition, we have prevention, care and treatment programs 
for HIV/AIDS across the continent, as well as food aid programs for 
millions of Africans.
    There is much to be done. Unlike other diseases, AIDS strikes 
people in the prime of their lives. This has profound effects on 
families, communities and nations. As Secretary of State Colin Powell 
has pointed out, ``the disease decimates a society's most productive 
members. It sickens those . . . who take care of the very young and the 
very old. It destroys those who teach and trade, support their families 
and otherwise contribute to their nation's development. AIDS saps 
global growth. Unchecked, AIDS can lay waste to whole countries and 
destabilize entire regions of the world.''
    In many villages across Africa, HIV/AIDS has wreaked havoc on food 
production. When someone is debilitated by disease, the food security 
of his or her family is in jeopardy. All too often families are forced 
to sell livestock and other valuable assets to care for the sick or to 
pay funeral expenses. This then compromises any future earning 
    For people living with HIV/AIDS, good nutrition is essential for 
continued good health. Yet, for too many people living with AIDS, 
getting enough to eat adds enormously to life's daily challenges.
    A lack of food can sometimes cause the epidemic to spread. We have 
heard too many stories of mothers who will trade the only resource they 
have--themselves--in exchange for food to feed their hungry children.

                     how food and aids interrelate

    Chronic malnutrition is increasing in sub-Saharan Africa. And the 
AIDS pandemic is exacerbating it.
    Let me take this opportunity to praise Jim Morris's leadership in 
responding to last year's food crisis in southern Africa. In his role 
as the UN Secretary General's Special Envoy, he helped alert the world 
and made an emergency request for funding. I'm proud that the U.S. 
Government took the lead in responding to the crisis and provided 
880,000 metric tons of food aid for the region, valued at $529 million 
over the past two years.
    We need to draw lessons from such experiences and apply them to our 
fight against the AIDS pandemic. We now realize that HIV/AIDS 
exacerbates food insecurity. But there is still much to be learned 
about the causes and consequences of this relationship. As we expand 
anti-retroviral treatment for people living with AIDS, there will be 
further issues to explore.
    We do know that HIV/AIDS affects a household's ability to produce 
food and earn income in several ways by:

   Reducing labor for farming due to illness, death and 
        additional caregiving responsibilities;

   Depleting food reserves, savings and productive assets, such 
        as livestock;

   Increasing household expenses, due to the costs of caring 
        for a chronically ill person or children orphaned by AIDS.

    Food assistance is the number one request made by people living 
with AIDS. It is key to improving overall health and quality of life. 
Malnutrition worsens the effects of HIV by further weakening the immune 
system and increasing susceptibility to infections. Good nutrition 
helps people living with HIV/AIDS manage symptoms and effectively 
respond to treatment.
    Conversely, HIV compromises the nutritional status of infected 
individuals. It creates additional nutritional requirements, causing 
symptoms that limit food intake and reducing the use of nutrients by 
the body.
    The World Health Organization believes that better nutrition 
increases survival rates, primarily because of its effects on immune 
functions. Increased caloric intake is recommended for HIV-infected 
adults because of their higher energy requirements. Once they have 
symptomatic HIV and full-blown AIDS, caloric intake needs to increase 
by 20 to 30 percent. For HIV positive children, once a child begins to 
experience weight loss, he or she must increase consumption by 50 to 
100 percent.
    Good nutrition is also important for patients receiving 
antiretroviral drugs, or ARVs, which are potent medications that often 
need to be taken with food. The use of the right combination of food 
and ARV treatment is important to ensure drug compliance and 
    We know that food insecurity and HIV/AIDS have profound 
consequences for nation states. We are only just beginning to 
appreciate the implications of the halving of adult life expectancy and 
the massive loss of human capital in many countries. In the most 
affected countries, HIV/AIDS has the potential to cripple the 
socioeconomic and political infrastructure, which is vital for 
stability as well as development.
                   usaid and presidential initiatives

    President Bush launched the Initiative to End Hunger in Africa in 
2002. It is a multi-year effort designed to help fulfill the Millennium 
Development Goal of halving the number of hungry Africans by 2015. We 
are urgently addressing the need to rapidly increase sustainable 
agricultural growth and augment rural incomes in sub-Saharan Africa. 
This approach will reduce the need for future food aid to the 
    Last year, P.L. 480 programs to prevent HIV and care for HIV-
infected children and their families reached at least 2.2 million 
people. Approximately 110,000 thousand tons of commodities, valued at 
$51 million, went into these programs.
    I would like to take this opportunity to note that this year marks 
the 50th anniversary of Food for Peace. P.L. 480 was enacted on July 
10, 1954, and for 50 years Title II has affected over 3 billion lives 
in over 150 countries. Since the inception of this program, which is 
implemented by USAID's Office of Food for Peace, the U.S. Government 
has provided over 100 million metric tons of food aid, valued at more 
than $33 billion, to reach people around the world. This is a program 
we can all be proud of because of its central role in helping save 
lives and alleviate suffering.
    USAID has been involved in the fight against AIDS since 1986, and 
today more than 100 countries around the world receive assistance from 
USAID in this fight.
    As President Bush has said, ``fighting AIDS on a global scale is a 
massive and complicated undertaking.'' That's why, just over a year 
ago, he announced the President's Emergency Plan for AIDS Relief, a 
visionary plan to increase spending on AIDS to $15 billion over 5 
years. I'm pleased that USAID is a key part of the team implementing 
this emergency plan. We are working closely under the leadership of the 
Global AIDS Coordinator, Ambassador Randall Tobias, who you will also 
hear from today.
               president's emergency plan for aids relief

    The Emergency Plan sets out three key goals to be achieved by 2008 
in 14 focus countries: Provide treatment to 2 million people, prevent 7 
million new infections, and provide care and support to 10 million 
people living with and affected by AIDS, including orphans and other 
vulnerable children.
    Today, I would like to discuss how USAID is assisting President 
Bush and Ambassador Tobias in meeting each of these goals, as they 
relate to food and HIV/AIDS.
    As we expand anti-retroviral treatment for people living with AIDS, 
there is much we can do to ensure a good relationship between food, 
nutrition and ARVs. We know that interactions between ARVs, food and 
nutrition can influence the success of treatment by affecting drug 
efficacy, adherence to drug regimens, and nutritional status of people 
living with HIV and AIDS.
    By strengthening food access and coping strategies of households 
and communities affected by HIV/AIDS, USAID is contributing to the goal 
of preventing seven million new HIV infections. In the area of food and 
nutrition, USAID programs are strengthening household resiliency 
through food-for-work programs and other income-generation activities. 
Food assistance is used for education and vocational training programs 
for children. And HIV/AIDS prevention messages are incorporated in all 
of these programs.
    Food and nutrition are critical components in the care of people 
living with HIV/AIDS and their families. Nutritional support has the 
potential to delay the beginning of life-threatening infections and 
ultimately prolong the lives of HIV-positive individuals. Family 
members who may depend on an infected person benefit as well.
    USAID is supporting a variety of activities to care for people 
living with AIDS, including:

   Food aid and nutrition counseling for people living with 
        AIDS and their families;

   Improved infant and child feeding for HIV-affected 

   Food aid to assist in management of opportunistic infections 
        such as tuberculosis; and

   Direct food aid to orphans and vulnerable children and 
        families looking after them.

    USAID's Office of Food for Peace invested over $17 million and 
approximately 40,000 metric tons of food aid to almost 700,000 HIV-
infected and affected adults and children in Haiti, Ethiopia, Kenya, 
Mozambique, Rwanda, South Africa, Uganda and Zambia--all focus 
countries of the President's Emergency Plan for AIDS Relief.
    Pascasie Mukamana is an orphan in Rwanda's Gitarama province. After 
her parents died of AIDS, she was forced to quit school to provide for 
her two sisters, one of whom is HIV-positive. With USAID funding, 
Catholic Relief Services provides a monthly food ration to Pascasie and 
her sisters. This is the story of just one of the 29,000 people USAID 
funding supports in Rwanda.
    In Uganda, for example, our partners report that in communities 
receiving food aid, school attendance is improving, there are fewer 
underweight children and people are able to work more regularly.
    The Consortium for Southern Africa Food Security Emergency is made 
up of World Vision, Catholic Relief Services and CARE. They focus on 
reducing food insecurity in targeted communities in Malawi, Zambia and 
Zimbabwe. Approximately 76,000 adults and children who are infected and 
affected by HIV/AIDS receive food through this consortium funded by 
    USAID's agricultural programs are also important in addressing the 
HIV/AIDS prevention response by ensuring that food is available to 
vulnerable households throughout the year. Other programs assist small 
farmers in accessing agricultural technology, or help them diversify 
their livelihoods to improve their food and nutrition security.
    For example, USAID supports the Regional Network of HIV/AIDS, Rural 
Livelihoods and Food Security in sub-Saharan Africa. The Network is 
analyzing the impact of AIDS on small farmers and focusing on how to 
maintain the productivity of staple crops in Malawi and analyzing the 
impact of AIDS on the agricultural programs in Uganda.
    Often, people do not have access to enough food to meet their basic 
daily caloric needs. Through the Harvest Plus Program, researchers are 
developing new varieties of wheat, rice, maize and cassava to enhance 
the nutrient content, quality and yield of these important staple 
crops. USAID is also supporting highly regarded universities in the 
U.S. and abroad who are turning their considerable expertise toward 
these issues.
    The Agriculture and Nutrition Advantage Program supports strategies 
that bring together national governments, non-governmental 
organizations, and research institutions to combat poverty, hunger and 
under-nutrition. It is critical to include these different stakeholders 
in efforts to address the complex challenges of food security, 
nutrition and HIV/AIDS.
    USAID is working with Michigan State University and Kenya's Egerton 
University to examine the relationship between AIDS and agriculture. 
Other research we've sponsored has found that relatively poor 
households do not recover quickly from head-of-household deaths.

                  partnership with world food program

    USAID has a long history of partnership with the World Food Program 
to provide food aid, and is the single largest donor to WFP. Last year, 
USAID's Office of Food for Peace provided over a billion dollars of 
food aid resources to the WFP. In addition, WFP receives support from 
USAID through the Joint United Nations Programme on HIV/AIDS, the 
umbrella organization for all of the U.N.'s work on HIV/AIDS, which 
will receive $26 million from my agency this year.
    Just last year, USAID's Office of HIV/AIDS entered into a new 
project partnership with WFP to specifically work on food aid for 
children affected by AIDS and their families. USAID is funding a unique 
partnership between the World Food Program and World Vision that is 
designed to use food to help keep children in school and reinforce and 
expand home-based care programs. WFP will provide food assistance that 
will complement World Vision's work and be linked to efforts to improve 
the overall family situation.

    I am proud of the work USAID is doing in the global fight against 
AIDS, poverty and hunger. By working through many different areas, 
USAID will help President Bush and Ambassador Tobias achieve a historic 
    USAID is in the unique position of having technical expertise in 
development, health and emergency response, as well as an extensive 
network of programs throughout the developing world. By building on 
these strengths, we will ensure that assistance gets to the neediest in 
a timely and transparent manner.
    I appreciate the opportunity to testify today on this important 


      Nutrition and HIV/AIDS: Evidence, Gaps, and Priority Actions

    In Africa, where more than 25 million people are living with HIV/
AIDS, malnutrition and food insecurity are endemic. Today, nearly 40% 
of African children < 5 years old are stunted due to chronic 
nutritional deprivation.\1\ Underweight, an indicator of chronic and 
acute malnutrition, was the leading cause of mortality worldwide, 
responsible for 3.7 million deaths in 2000.\2\ Nearly half of these 
deaths (48.6%) occurred in sub-Saharan Africa.
    The effects of malnutrition on the immune system are well known and 
include decreases in CD4 T-cells, suppression of delayed 
hypersensitivity, and abnormal B-cell responses.\3\-\4\ The immune 
suppression caused by protein-energy malnutrition is similar in many 
ways to the effects of HIV infection.\5\ This document summarizes the 
evidence, gaps, and priority actions related to nutrition and HIV/AIDS.

             nutrition and hiv/aids: the evidence and gaps

    HIV-infection increases energy requirements. HIV infection affects 
nutrition through increases in resting energy expenditure, reductions 
in food intake, nutrient malabsorption and loss, and complex metabolic 
alterations that culminate in weight loss and wasting common in 
AIDS.\6\-\7\ The effect of HIV on nutrition begins early in the course 
of the disease, even before an individual may he aware that he or she 
is infected with the virus.\8\-\10\ Asymptomatic HIV-positive 
individuals require 10% more energy, and symptomatic HIV-positive 
individuals require 20%-30% more energy than HIV-negativc individuals 
of the same age, sex, and physical activity level.\11\
    The impact of pre-existing malnutrition on HIV susceptibility and 
disease progression is difficult to study, and knowledge in this area 
is still limited. A systematic review of the literature is now underway 
by the World Health Organization (WHO).\11\ Early studies demonstrated 
that weight loss and wasting were associated with increased risk of 
opportunistic infections \12\ and shorter survival time in HIV-positive 
adults, independent of their immune status.\13\ \14\ Other studies 
showed that clinical outcome was poorer and risk of death was higher in 
HIV-positive adults with compromised micronutrient intake or 
    Micronutrient deficiencies may contribute to disease progression. 
Deficiencies of vitamins and minerals, such as vitamins A, B-complex, 
C, and E and selenium and zinc, which are needed by the immune system 
to fight infection, are common in people living with HIV.\9\ \21\ 
Deficiencies of anti-oxidant vitamins and minerals contribute to 
oxidative stress, a condition that may accelerate immune cell 
death\22\-\23\ and increase the rate of HIV replication.\24\-\26\
    Daily micronutrient (antioxidant) supplementation improved body 
weight and body cell mass \27\ reduced HIV RNA levels; \28\ improved 
CD4 cell counts;\28\ and reduced the incidence of opportunistic 
infections \29\ in small studies of adults with AIDS, including those 
on antiretroviral therapy. Larger clinical trials demonstrated that 
daily micronutrient supplementation increased survival in adults with 
low CD4 cell counts; \30\ prevented adverse birth outcomes when given 
during pregnancy; \31\ and reduced mother-to-child HIV transmission in 
nutritionally vulnerable women with more advanced HIV disease.\32\ The 
optimal formulation of a daily multiple micronutrient supplement for 
HIVpositive individuals requires further study.\11\
    Antiretroviral therapy improves nutritional status, but ARVs may 
also have side effects and metabolic complications. Highly active 
antiretroviral therapy (HAART) improves nutritional status, independent 
of its effects on viral suppression and immune status,\33\ although 
wasting still develops in some patients.\34\ ARV side effects such as 
nausea and vomiting may affect adherence to therapy, particularly in 
the first months of treatment.\35\ Additional metabolic complications 
such as derangements in glucose and lipid metabolism, bone metabolism, 
and lactic academia have been associated with the use of certain ARV 
drugs.\36\ Research on the metabolic consequences of ARV therapy and 
appropriate strategies for their management is a growing field in 
industrialized countries. Further research is needed in resource-
limited settings, where management options and follow-up monitoring may 
be more limited.
    HIV-exposure and infection exacerbates problems of child 
malnutrition. Children living with HIV or born into families affected 
by HIV are a high-risk group with special needs. HIV-positive women 
have a higher incidence of preterm and low birth weight deliveries, 
and, as a result, HIV-exposed infants may start life with impaired 
nutrition.\37\-\38\ HI V-positive infants experience slower growth and 
are at greater risk of severe malnutrition.\39\-\40\ Studies show that 
severe malnutrition in HIV-positive children can be reversed with 
hospital and home-based therapeutic feeding, though the time to 
recovery is longer than with uninfected children.\41\ Studies also 
indicate that periodic vitamin A supplementation reduces morbidity and 
mortality in HIV-positive children and improves their growth.\42\-\44\
    Optimal infant and young child feeding practices are crucial in the 
context of HIV/AIDS. Breastfeeding practices may also affect the health 
of HIV-exposed children. The risk of HIV transmission through 
breastfeeding is directly related to the health, viral load, and immune 
status of their mothers. Infection occurs at an average rate of about 
8.9 HIV transmissions per 100 child-years of breastfeeding.\45\ HIV-
positive mothers are recommended to avoid breastfeeding if replacement 
feeding is feasible, affordable, and safe.\46\ In many resource-limited 
settings, this cannot be assured, and many HIV-positive women initiate 
breastfeeding.\47\-\48\ For these women, exclusive breastfeeding and 
early breastfeeding cessation are recommended.\46\ Infants who are not 
breastfed or who stop breastfeeding early and do not have access to 
safe and nutritious replacement foods are at increased risk of 
malnutrition, diarrhea and other illnesses, and death.\49\

     livelihoods, food security, and hiv/aids: complex interactions

    Food security is the state in which all people have both physical 
and economic access to sufficient food to meet their dietary needs for 
a productive and healthy life at all times.\50\ Achieving this state is 
contingent on food being available, accessible, and utilized by the 
body. The relationship between HIV/AIDS, livelihoods, and food and 
nutrition security is complex and multidimensional.
    Food insecurity and poverty may lead to high-risk sexual behaviors 
and migration, increasing the risk of acquiring HIV infection.\51\-
2\52\ HIV/AIDS, in turn, significantly undermines a household's ability 
to provide for basic needs. Livelihoods are diminished when HIV-
infected adults cannot work and food production and/or earnings 
decrease. Healthy family members, particularly women, are often forced 
to stop work to care for sick family members, further reducing income 
for food and other basic needs. Household labor constraints can cause 
reductions in cultivated area, shifts to less labor- or cash-intensive 
crops, and depletion of livestock.\53\
    Food-insecure households frequently struggle to meet ordinary 
household needs without the added stress of HIV. Their capacity to 
absorb the costs associated with HIV-related illnesses, to provide 
enhanced nutritional support, and to participate in community programs 
is severely restricted, and many find themselves in a rapid downward 
economic spiral.\54\ The spiral is made worse when disabled parents are 
unable to pass on practical crop and livestock knowledge,\51\ \55\ and 
when children are withdrawn from school because of difficulty paying 
fees or the need for the young to care for ill family members, 
jeopardizing their future income-earning potential.
    HIV/AIDS is impacting entire communities, with rippling effects, 
particularly in areas that are highly dependent on labor. For example, 
in rural Kenya, when HIV affects a relatively wealthy household and 
spending on health care increases, money to hire laborers declines. 
Poorer households become increasingly more vulnerable--food insecure, 
less able to send their children to school, and less able to meet their 
own health needs--when they can no longer find work because the 
wealthier families can not afford to hire them.\56\ Entire communities 
are weakened by HIV, not just individuals, and traditional community 
safety nets are being stretched to their limit in highly affected 
                            priority actions
    Nutrition counseling, care, and support are integral to 
comprehensive HIV care, including care given to HIV-positive 
individuals and orphans and vulnerable children (OVC). There are 
several nutrition and food-related interventions to consider. 
Appropriate actions depend on the local conditions, the HIV-positive 
individual's lifecycle state (e.g., child, pregnant or lactating, other 
adult), degree of disease progression (e.g., asymptomatic, symptomatic, 
AIDS), and whether they have initiated ARV therapy. Integrating 
nutritional care and support interventions strengthens home-, clinic-, 
and community-based care, ARV services, OVC activities, and national 
policies and strategies addressing the pandemic. Nutrition 
interventions may improve the quality and reach of care and promote 
successful treatment.
    The main nutrition interventions are counseling on specific 
behaviors, prescribed/targeted nutrition supplements, and linkages with 
food-based interventions and programs. Three different types of 
nutrition supplements are considered: food rations to manage mild 
weight loss and nutritional-related side effects of ARV therapy and to 
address nutritional needs in food-insecure areas; micronutrient 
supplements for specific HIV-positive risk groups; and therapeutic 
foods for rehabilitation of moderate and severe malnutrition in HIV-
positive adults and children. Priority actions are:
    Nutrition for positive living. This includes nutrition counseling 
and support to improve food intake and maintain weight during 
asymptomatic HIV infection and to prevent food and waterborne 
infections. Food rations may be provided in food-insecure areas and for 
nutritionally vulnerable pregnant and lactating women. Daily multiple 
micronutrient supplements may be provided to HIV-positive pregnant 
women in areas where malnutrition rates are high, although the optimal 
formulation for such supplements is not yet known.
    Nutritional management of HIV-related illnesses. This includes 
counseling to manage nutrition-related symptoms of common HIV-related 
illnesses/opportunistic infections (e.g., loss of appetite, oral sores, 
fat malabsorption). Home-based care programs, community efforts, and 
clinical services can provide counseling to help HIV-positive 
individuals and their households optimally use available foods to 
manage symptoms and maintain food intake. Guidance and materials to 
support nutritional management of symptoms, developed with USAID 
assistance, are already available in many countries.
    Management of ARV interactions with food and nutrition. This 
includes providing information and support to help ARV clients manage 
side effects such as nausea and vomiting and prevent drug-food 
interactions. Side effects and interactions can negatively affect 
medication adherence and efficacy. Supporting ARV clients in 
appropriate dietary responses to manage these conditions helps ensure 
successful treatment. In addition to nutrition counseling, food rations 
may be provided in food-insecure areas, particularly in cases where 
lack of food is interfering with treatment adherence and among those 
experiencing weight loss that is not reversed after treatment is 
    Therapeutic feeding for moderately and severely malnourished HIV-
positive children and adults. This includes hospital-based 
stabilization and home- or community-based care using therapeutic 
(nutrient-dense) foods, per WHO or local nutrition rehabilitation 
protocols. The foods and protocols used to treat severe malnutrition in 
the general population may be used for HIV-positive patients, although 
some adaptations may be required for adults and those experiencing 
severe symptoms.
    Infant and young child nutrition for HIV-exposed children. This 
includes counseling on feeding options for HIV-exposed children, 
including orphans, and support for safer breastfeeding or replacement 
feeding, per WHO or local protocols. Food rations, therapeutic foods, 
and micronutrient supplements may also be provided, depending on local 
circumstances such as food availability, diet quality, and malnutrition 
rates. Vitamin A supplementation is recommended, per WHO protocols.
    Palliative care and community coping mechanisms. This includes 
nutrition counseling and supplements for HIV-positive and HIV-affected 
households delivered through home-, clinic-, and community-based care 
programs and strengthening links to social support organizations, 
building community food stocks, sharing labor, modifying costly customs 
(funerals, marriages), and providing food assistance and training to 
widows, orphans, and vulnerable children. The U.S. Government, through 
USAID, has Title II programs providing this type of assistance in 
several countries, including Ethiopia, Haiti, Kenya, Mozambique, 
Rwanda, Uganda, and Zambia. The USAID-funded C-Safe Program is linking 
Title II food to HIV home-based care programs in Zambia, Malawi, and 

                     Summary of Nutrition Interventions According to HIV Disease Progression
                                                                                            Families Affected by
    Interventions        HIV+ Asymptomatic       HIV+ Symptomatic             AIDS          an HIV-related Death
Counseling/care        Nutrition education    Nutrition management   Nutrition management   Counseling on
                        and counseling for     of HIV-related         of ARV therapy         special food and
                        positive living.       opportunistic          (where available).     nutritional needs
                                               infections (OI),                              of orphans and
                                               symptoms, and                                 vulnerable infants
                                               medications.                                  and young children.
                       .....................  .....................  Nutrition management   ....................
                                                                      in home-, clinic-
                                                                      and community-based,
                                                                      palliative care.
 Prescribed/targeted    For high-risk groups   For high-risk groups.  Therapeutic feeding    For high-risk groups
 nutrition              only (e.g., pregnant                          for moderately and     (e.g., HIV-exposed
 supplementation        and lactating HIV+                            severely               non-breastfed
                        women, HIV-exposed                            malnourished HIV+      children < 2 yrs or
                        non-breastfed                                 adults and children.   HIV-exposed
                        children).                                                           children with
                                                                                             growth faltering).
                       .....................  For persons who are    .....................  ....................
                                               losing weight or do
                                               not respond to
                       .....................  Therapeutic feeding    .....................  ....................
                                               for moderately and
                                               malnourished HIV+
                                               adults and children.
 Other food             To prevent             To improve adherence/  To improve adherence/  To protect the
 interventions          nutritional            participation in OI    participation in ARV   health of orphans
                        deterioration for      treatment programs.    and OI treatment       and vulnerable
                        HIV-affected                                  programs.              children and for
                        families living in                                                   surviving family
                        highly food-insecure                                                 members when
                        communities.                                                         livelihoods are
                                                                                             compromised because
                                                                                             of HIVrelated
                                                                                             sickness or death.
                       .....................  .....................  To use in home-,       ....................
                                                                      clinic-, and
                                                                      community-based care

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    The Chairman. Well, thank you very much for that testimony.
    Let me ask Senator Alexander. Do you want to raise a 
question before you depart?
    Senator Alexander. No, thank you, Mr. Chairman. I did want 
to come and hear the testimony and commend you for your focus, 
and I have been following very carefully sub-Saharan Africa 
through Ambassador Tobias. I thank you for the chance to hear 
the testimony. Thank you, Mr. Chairman.
    The Chairman. Well, thank you. Senator Alexander serves, as 
you know, as the chairman of our Subcommittee on African 
Affairs. Also, the distinguished ranking member, Senator 
Feingold, is with us.
    I will defer my questions and recognize Senators Feingold 
and Boxer with perhaps a 10-minute limit on our first round.
    Senator Feingold. Thank you very much, Mr. Chairman. I 
thank the witnesses very much for your important testimony.
    Mr. Morris, I appreciate your expertise on the issues 
before us and your consistent efforts to call the world's 
attention to the linkages between food security, HIV/AIDS, and 
nutrition, but I want to take this opportunity to just followup 
a little bit on the specific humanitarian crisis that has 
already been discussed today, the situation in Darfur. You 
acknowledged it, as did the chairman, obviously because it is 
such a desperate and urgent situation.
    Will you just lay out a little bit more for the record 
today how many people are at risk of malnutrition in the 
region? At this point, is the WFP able to get urgently needed 
relief supplies to displaced people in Darfur, and what 
specific conditions must change to enable the WFP to deliver 
needed supplies to these vulnerable people?
    Mr. Morris.
    Mr. Morris. Thank you, Senator.
    Today in the three provinces of Darfur, west, south, and 
north, there are 1 million internally displaced people. There 
are another 100,000 people affected by the conflict still in 
Darfur. We believe that the number by the end of the year, 
given the fact that this year's harvest will be lost, will 
increase by another 800,000 people. Today there are 53,000 
refugees in camps in Chad in five camps, another 42,000 people 
who are living on the perimeter of the camps in ramshackle 
    One of our great concerns is the number of refugees. People 
are leaving the Sudan to Chad for security reasons. People are 
very frightened and justifiably in the Sudan. They are afraid 
to venture out of the camps. They know if they go to Chad and 
live in the camps there, that security issue will be 
diminished. Chad had anticipated five camps. The numbers are so 
large that they will now have 10 camps because the water 
available per camp is not adequate to handle the numbers that 
are there now.
    We have a rainy season ahead of us in a matter of days. We 
will be able to preposition the food we need to preposition in 
Chad. It will be something in the neighborhood of 7,000 metric 
tons of food. It will be difficult. We will move part of it 
across from Cameroon, and we now have a new understanding with 
the Libyans that we can move food down from Libya into Chad and 
the Chad Government has said that is acceptable.
    Senator Feingold. What about those in Darfur?
    Mr. Morris. I am coming to that. This is more difficult. 
Half the people in Darfur are living in camps and half are 
living in the hills or simply wandering about. As you drive 
through the area, you see village after village that has been 
destroyed. The homes have been burnt. The landscape is strewn 
with pots and pans. Their clothing has been taken. The 
livestock is gone. Maybe a village that once had 300 families 
today might have three older men, each weighing about 75 
pounds. Really tragic.
    The report I read this week suggests that we have been able 
to provide food for about 800,000 people in Darfur. That is a 
substantial increase. We are working very, very hard to get 
food prepositioned for the rainy season. It will be difficult 
to do that job either satisfactorily or perfectly. We will do a 
lot of it. USAID has food that will arrive toward the end of 
the month. USAID has made another commitment in support of our 
work. We have also had new commitments from the European 
Community from Luxembourg, from the United Kingdom, and several 
other places. We have committed resources from our own internal 
emergency response account to buy sorghum which is available in 
the country. We sort of have $30 million set aside to do that 
    So we are working very hard to get it prepositioned. We 
know that we are going to have to airlift some of that. The 
World Food Program also operates the United Nations 
Humanitarian Air Service, and so we provide air support for all 
of the U.N. family, all of the NGO family. It is more 
expensive, but we get in very difficult circumstances and we 
will use it to air drop or transport by air some food.
    Senator Feingold. Thank you, Mr. Morris. I appreciate your 
answer. I just want to get in one more question of Mr. Tobias, 
but I am grateful for your response and I will followup with 
you afterward.
    I have worked with Senator Brownback and Senator Alexander 
and other members of the committee, including the chairman and 
the ranking member, to pass a resolution last week addressing 
this issue that you were very effectively addressing, Mr. 
Morris. I think it is critically important that we not let this 
issue slip off our radar screen.
    Mr. Morris. I forgot that my comments took part of your 10 
minutes. So forgive me.
    Senator Feingold. They were incredibly important things you 
were discussing and I did want some of that information on the 
record. So I thank you.
    Ambassador Tobias, it is good to see you again. I 
appreciate your consistent efforts to be available to this 
committee and to Members of Congress to ensure that the vast 
coalition committed to fighting AIDS does not fray.
    The last time we spoke, you were testifying at an African 
Affairs Subcommittee hearing on implementation of the Emergency 
Plan for AIDS Relief, and we discussed the issue of generic 
fixed-dose combination therapy. As you know, I and many others 
have been concerned about the administration's unwillingness to 
use drugs that are prequalified as safe and effective by the 
World Health Organization, which are actually easier to use and 
cheaper than drug regimens that we are buying. You indicated 
then that you were hopeful that we would be able to move 
forward on this issue and to answer the underlying questions 
that have led to this problem.
    Would you please provide me with an update for the 
committee on the progress that has been made since that hearing 
to resolve that issue?
    Ambassador Tobias. Well, Senator, I continue to be 
optimistic that we are making progress on getting our hands 
around this problem. As we have discussed before, the World 
Health Organization's prequalification program is just that. It 
is a prequalification program. It serves a very useful purpose 
in those parts of the world where there is not a stringent 
regulatory process.
    But as we gear this up, we are dramatically expanding the 
number of people who will be under treatment in the world, and 
we are also going to dramatically expand, I suspect, the number 
of entrants who are coming into this market. I have had two 
heads of state in Africa tell me that they intended to go into 
this business themselves, and we need to ensure that we have a 
process in place that will provide assurances of safety and 
effectiveness to the patients who will be treated. I have 
spoken to a number of officials and medical people in Africa 
who are as concerned about that as we are.
    But I am even more, let me say, optimistic than when you 
and I last talked that we are on a path that in the weeks ahead 
we are going to have processes in place that will permit us to 
take a good, hard, scientific look at the safety and efficacy 
of drugs from all over. I certainly look forward to having that 
    Senator Feingold. Well, I thank you for your update. This 
is so incredibly urgent that I hope this can move as quickly as 
possible, and I am interested in each and every step forward 
that we can take.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Feingold follows:]

           Prepared Statement of Senator Russell D. Feingold

    I thank Chairman Lugar and Senator Biden for holding this important 
hearing, and I thank all of our witnesses for being here today.
    In July 2002, in the midst of the horrible headlines about food 
crisis in Southern Africa, I asked the General Accounting Offices to 
look into the underlying causes of the crisis and the U.S. response. 
Their report, issued in June 2003, made clear that one cannot look 
seriously at food security issues in Africa without also considering 
the consequences of the HIV/AIDS pandemic. The report found that AIDS 
had exacerbated the food crisis by reducing productivity and 
agricultural output and by dramatically limiting the capacity of 
communities to cope with hardships like a bad harvest, or rising food 
prices. In other words, AIDS has made already vulnerable communities 
more vulnerable, such that setbacks that might not have been 
catastrophic before can now push people over the edge into crisis.
    At the same time, no one who has been on the ground to look at the 
nature of the AIDS crisis can escape the conclusion that good nutrition 
and food security are necessary ingredients for the success of 
initiatives to fight AIDS. Medical interventions must occur in a 
context of sound nutrition if they are to succeed, and, more broadly, 
overall economic insecurity, including food insecurity, can render 
specific populations, like women and girls, especially vulnerable to 
contracting AIDS.
    We can all be proud of the efforts that the U.S. Government has 
made thus far to fight hunger and to fight AIDS around the world. This 
hearing is a good opportunity to explore how we might make our taxpayer 
dollars go further by ensuring that our efforts on these interrelated 
fronts are well thought out and well coordinated.
    I look forward to exploring these important issues today.

    The Chairman. Thank you very much, Senator Feingold.
    Senator Boxer.
    Senator Boxer. Thank you very much, Mr. Chairman.
    I am going to take this opportunity to make a statement 
about another issue for 5 minutes and then direct an important 
question to the Honorable Randall Tobias.
    Mr. Chairman, we have three individuals sitting before us 
who exemplify the best in what America is all about, giving 
themselves to an issue that needs leadership for the most 
vulnerable people on the face of the Earth right now. And I am 
very proud that you have asked them up here.
    Now, in another part of the world, sadly to our horror, we 
see other Americans with different agendas and different 
values, albeit in a different job. I just want to take this 
chance because this committee has been in many ways prescient 
on the issue of Iraq, both sides saying where is the plan, 
where is the plan.
    I just want to take this moment to put into the record an 
article \3\ that appeared today in the Los Angeles Times, if I 
might. A double ordeal for female prisoners. It is written by 
Tracy Wilkinson, who is a reporter that I've known for many 
years, actually covered one of my races, my first race many 
years ago, and now has been covering the Iraqi situation, got 
injured in a blast in a restaurant and is still there 
reporting. That is Tracy Wilkinson.
    \3\ The article referred to can be found on page 57.
    So I just want to read you one or two paragraphs of this 
story, and keep in mind that in the Muslim culture--and, Mr. 
Chairman, you know this--where it is forbidden to remove your 
scarf in front of a strange man, ``One woman told her attorney 
she was forced to disrobe in front of male prison guards. After 
much coaxing, another woman described how she was raped by U.S. 
soldiers. Then she fainted.
    ``A U.S. Army report on abuses at Abu Ghraib prison 
documented one case of an American guard sexually abusing a 
female detainee, and a Pentagon spokesman said Monday that 
1,200 unreleased images of abuse at Abu Ghraib included 
`inappropriate behavior of a sexual nature.'
    ``Whether it was one or numerous cases of rape, many Iraqis 
believe that sexual abuse of women in U.S.-run jails was 
rampant. As a result, female prisoners face grave prospects 
after they are released: denial, ostracism or even death.
    ``A woman who is raped brings shame on her family in the 
Islamic world. In many cases, rape victims have been killed by 
their relatives to salvage family honor, although there is no 
evidence this has happened to women who have been prisoners in 
    `` `It is like being sentenced to death,' said Sheik 
Mohammed Bashar Faydhi, a senior cleric based at Baghdad's 
largest Sunni mosque.''
    The reason I took the time to read this is because I know, 
Mr. Chairman, that you were working hard to set a hearing next 
week on Iraq, and I am hoping that you can have some witnesses 
at that time from very high up who could talk about what kind 
of restitution and help we are going to give these women. They 
face a special stigma in that culture, and since Secretary 
Rumsfeld had talked about restitution, I think this is 
something they ought to be prepared to discuss perhaps, if you 
agree with me, in their opening remarks. If not, I will bring 
it out in the questions.
    The Chairman. I can respond quickly to the Senator. We have 
been in touch with the Pentagon and the State Department. We 
are advised that Secretary Wolfowitz and Secretary Armitage 
will be with us.
    Senator Boxer. That is wonderful.
    The Chairman. So I will convey to them your questions so 
they will be prepared.
    Senator Boxer. Thank you so much. And I will make available 
this article to them.
    Mr. Chairman, now getting to the issue before us today. 
Again, thank you to our witnesses, all.
    I would ask unanimous consent to place in the record a 
letter that was sent to Ambassador Tobias on March 26, 2004, 
signed by 370 U.S. and international organizations.\4\ So I 
would ask that that be included in the record.
    \4\ The letter to Ambassador Tobias can be found on page 58.
    The Chairman. It will be included in the record in full.
    Senator Boxer. My question, Mr. Ambassador, is this. One 
important link between hunger and HIV/AIDS is the high cost of 
antiretroviral drugs. That forces people to sell their 
farmland, thereby making food more scarce. Yet, there are 
charges that the administration has worked to block the use of 
affordable generic HIV/AIDS medicines that have been approved 
by the World Health Organization. So this group--and I will not 
read the entire letter--has in their last paragraph--and I 
would like you to comment on this, whether you agree, disagree, 
and where you stand on this--``Rather than disregarding the 
drug procurement policies of developing nations to create 
expensive new barriers that benefit U.S. drug companies, your 
office should accept the WHO's internationally recognized drug 
quality standards and promote access to affordable medications. 
We object to any and all efforts by the administration and your 
office to block the use of WHO prequalified generic 
medications, and any efforts to discredit the standards of 
WHO's prequalification project that would impose new barriers 
to generics entering the global market.''
    So, the charges in this letter by some of the most 
respected organizations in this country and abroad are strong. 
How do you respond to this charge given that only 50,000 
Africans now have access to AIDS treatments and that 8,000 
people are dying from AIDS every day? Ambassador, your answer 
to this question is really important. It may link to what you 
said to Senator Feingold, but frankly, I found that answer to 
be so vague.
    Could you tell me when you are going to respond to this 
issue? Is there hope that this administration would back the 
WHO plan? Because it is all well and good and we all bemoan 
what is happening and it is all heartfelt, but if we are 
withholding lifesaving medicine from people, Mr. Chairman, I do 
not know how we can go to sleep at night, to tell you the 
truth. So could you respond to that?
    Ambassador Tobias. Senator, thank you.
    The issue of the availability of antiretroviral drugs as a 
component of making more broadly available treatment for 
patients is obviously critically important. Right now, it is 
not the limiting factor in expanding treatment. The limiting 
factor in expanding treatment is the availability of physical 
facilities and medical personnel, and we are working very hard 
on all of these issues.
    The WHO process, which plays a very important role, as does 
the WHO, in the total effort to fight HIV/AIDS, I think has 
been misconstrued by a number of people as an approval process, 
and it is not. The WHO's own program has a caveat saying that 
drugs that are listed on this prequalification list are not 
warranted as to their safety and efficacy.
    We need a more stringent process and we are working with 
the WHO, with other officials in international agencies around 
the world in a very cooperative effort to get a process in 
place that can provide the kind of regulatory scrutiny that we 
have come to expect here in the United States. We are about to 
scale up. We are in the midst of scaling up treatment on a very 
massive scale, and it is very, very important that we get this 
    I am obviously very aware of the letter that you refer to. 
I have other letters from other people, including a letter I 
received yesterday from physicians at Stanford University 
urging that we do exactly what we are doing. I think that shows 
that reasonable people can disagree on what the proper approach 
is here.
    But no one is working any harder than I am to move this as 
rapidly as we can because there will come a time when the 
availability of drugs will be the limiting factor. That is not 
really yet the case, but we need to move as quickly as we 
possibly can and that is certainly what we are doing, Senator.
    Senator Boxer. If I could just say this to you, I am a 
person suffering, lost, sitting in some house with my oldest 
child trying to raise my family and I have no drugs, yes, I 
want the safest drugs. I want the safest, but if I have 
nothing, I am in a worse situation.
    I would just say to my friend--and I respect you very 
much--when I look at the people who signed this--you said you 
got letters from other people--this is not people. These are 
thousands of people. The people who signed this letter: the 
International Association of Physicians in AIDS Care, Oxfam, 
the Ecumenical HIV Initiative in Africa, World Council of 
Churches, African Jesuit AIDS Network, Episcopal Church USA, 
Presbyterian Church USA, Unitarian Universalist Association of 
Congregations, Amnesty International, American Foundation for 
AIDS Research, ActionAid International USA, American Medical 
Students Association, Church Women United, Commission on Social 
Action of Reform Judaism. And it goes on and on. Operation USA. 
This is just in America, not to mention the world.
    So I would just say to my friend please understand that it 
is all important, getting the medicine to the people, getting 
the medicines approved, getting affordable medicines. It is all 
important and I would just suggest to my friend that this is a 
pretty powerful letter here, and there are charges out here 
that there are drug companies that do not want to see this 
happen. This is about an American value. So if there is 
anything I can do to work with you on this, please let me know 
because I know that you want us to be successful here.
    And this is a question, Mr. Chairman, of our values. It 
seems to me if we are caught in a values battle over providing 
medicine to people versus protecting pharmaceutical companies, 
I know where you would come down and I know where I would come 
down. This is very worrisome to me. That is what these people 
are saying and they are not people who do not think hard. So I 
am very worried and I will continue to work with my chairman on 
this in the hopes that we can get these generics out there as 
soon as possible.
    Thank you.
    The Chairman. Thank you very much, Senator Boxer.
    Let me begin my questioning by asking Mr. Morris about the 
Zimbabwe life expectancy figure that you mentioned. If I got 
the notes correctly, you indicated life expectancy at some 
point was at 67 and this is now 33. Is that correct?
    Mr. Morris. That is correct.
    The Chairman. This is, just on the face of it, an awesome 
result in one country. You made the point strongly, but it may 
just simply float over most of us--that we are really talking 
about the future of some countries on this Earth when you have 
that dramatic a change in the life expectancy in a relatively 
short period of time. This denotes that at least half of the 
population is likely to be gone in a much shorter period of 
time than anyone could have anticipated.
    We have heard testimony on this subject from our 
ambassadorial nominees. The committee asks each one, just 
simply because their orientation now gets into malnutrition and 
HIV/AIDS, about life expectancy, about the number of persons 
infected in the countries. These statistics mount up as we have 
each round of Ambassadorial nominees. So there is a 
comprehension on the part of the Congress and the American 
people of the severity of this, but it is so large that it is 
almost beyond our understanding in a way.
    We commented, I think, when we last had a hearing in which 
you were involved that essentially, if anybody reported a 
battle today somewhere on Earth in which a few hundred people 
lost their lives, this would be of enormous significance in our 
24-hour news coverage. From almost every angle, the devastation 
of those lives and the circumstances would be very, very 
important. But as you point out in your testimony, here we have 
a situation in which approximately 24,000 people are losing 
their lives every day from malnutrition, and an additional 
7,000 to 8,000 people from HIV/AIDS, or a combination of that 
and tuberculosis, a lack of immunity. They are passing away 
without notice every single day.
    As I said, the enormity of this figure is so large that 
many people, before they even get into the issue, conclude that 
this is beyond our ability to affect. You have not taken that 
position, nor has our government. The purpose of the hearing 
today is both to illustrate what we are doing, but even more 
importantly to encourage the cooperation between agencies of 
our government, the United Nations, and private voluntary 
organizations that play such a vital role in this respect, 
because that often is not evident. I just wanted to use the 
Zimbabwe case as an especially dramatic example.
    We have commented, for instance, on national security 
hearings, during which we deal with Russia. Russia has had a 
disturbing trend in terms of life expectancy. Some Russians 
would say that that has been arrested. Male life expectancy has 
declined over the course of the last 20 years from somewhere in 
the mid-1960s to the mid-1950s. It may have leveled off in the 
high 1950s for the average Russian male, but for a country of 
that size and scope to have that kind of demographic change 
already leads many Russians to believe that there will be many 
fewer Russians, and that the population of the country is 
already in decline. This comes at a time in which burgeoning 
economies in Asia, for example, are gaining a huge population, 
in addition to experiencing per capita growth of significant 
percentages year by year, thus changing the whole perspective 
both demographically and with regard to national security 
issues for those countries.
    This hearing is meant to illustrate and to serve as a 
benchmark for the seriousness of the problem.
    Now, second, Mr. Tobias. The normal questioning of the AIDS 
program by Members of Congress comes down to two issues. First, 
the President, in the State of the Union Address, and then in 
subsequent messages, has talked about $15 billion of 
expenditure over 5 years of time. During the debate that we had 
on the Senate floor, many Senators were critical of the fact 
that the initial request was for $2 billion. People say, well, 
do the math. Take 15, divide by 5, it is 3. It is not 2.
    Now, at the time--this is before you came along, and before 
your confirmation--why, administration people said not to 
worry. There is only so much you can do. We are gearing up in 
the first year. Therefore, it makes sense not to promise more 
than we can deliver, and besides, $1 billion is $1 billion. You 
do not want to commit it and spend it before you really are 
geared up to do that.
    In any event, we debated this all year in one forum after 
another. And at the end of the day, the 2 was raised to about 
2.4 or thereabouts.
    Now, the second year comes along and once again, the figure 
is somewhere in the 2's, not 3. So members are saying, well, 
all right. You had a year to gear up and yet we are not batting 
very well. Friends of the program, such as the singer Bono, 
came through. He is a good friend of the committee. We visit 
frequently. I mention him as one who would say, why not? Why do 
the math again and so forth? This is one area I want you to 
    The other area was touched upon by Senator Boxer. Despite 
all protestations, there is simply a fundamental conflict here 
between the pharmaceutical companies, not just American 
companies, but companies all over the world, who have a profit 
objective. All of you talking here today, you have a 
humanitarian objective. The people that we are talking about 
are dirt poor. There is just no money involved, not very much 
in the governments. Paying for these drugs and/or treatments, 
as well as the infrastructure, which as you say, may be the 
limiting factor now, is very expensive.
    This comes over into our domestic debate frequently on 
Medicare. We go back and forth over this subject. Why do senior 
citizens go to Canada? Why do they go elsewhere to buy drugs 
more cheaply? And why do we not price our drugs differently? 
The pharmaceutical companies testify about their research 
budgets and the need to amortize this. We go round and round.
    When we come to the AIDS business, and people dying in 
these numbers, as the Senator had mentioned, and the gaps 
there, why, this becomes especially acute.
    Why do we not spend $3 billion a year? Why is this dispute 
persisting? If there is cooperation from the pharmaceutical 
companies, tell us more about it. If there are problems, 
discuss that too and how we could be constructive.
    Ambassador Tobias. Senator, I am just back from Mozambique, 
a country with a population of something between 17 million and 
18 million people and physicians in Mozambique numbering 
somewhere between 500 and 600. Those physicians are almost 
entirely located in the urban areas. That is an equation that 
illustrates the problem, a ratio of 1 physician on average, if 
they were spread out all across the population, of something 
between 1 and 20,000 to 30,000 people.
    The Chairman. This is all the doctors there are in 
    Ambassador Tobias. All the doctors there are in Mozambique. 
Mozambique, because of the language, the Portuguese language, 
is not losing doctors to other countries as is the case in some 
other parts of Africa. For example, there are more physicians 
who are Ethiopian citizens living in Chicago, Illinois, than 
the entire country of Ethiopia.
    So the problem that we face in getting treatment programs 
geared up is not, with all due respect to concerns expressed by 
many people, today largely one of the availability of drugs or 
the price of drugs. It is in getting the infrastructure and the 
people in place to deliver this treatment. Drugs are very 
important to this, and I will come to that in a second. But it 
is right now more an issue of getting the infrastructure in 
place, getting different models in place. We need to get models 
in place where physicians are saying to themselves, what am I 
doing that does not absolutely have to be done by a physician 
and we can bring someone else into the equation to help get 
that done.
    The Chairman. Just on that point, is there data that the 
committee could have on how many physicians there are in each 
of the African countries?
    Ambassador Tobias. Yes, there is.
    The Chairman. And then beyond that, as you mentioned, how 
many nurses or other health professionals? This would help 
Members of Congress to begin to get a perspective of this 
delivery problem in a way that clearly many of us do not yet 
    Ambassador Tobias. We can make that data available.
    [The following response was subsequently supplied.]

                         United States Department of State,
                                       Washington, DC, May 24 2004.

The Honorable Richard G. Lugar, Chairman,
Committee on Foreign Relations,
United States Senate.

    Dear Mr. Chairman:

    During Ambassador Randall L. Tobias's May 11 appearance before the 
Committee to testify on the important issue of HIV/AIDS and hunger, you 
and Ambassador Tobias discussed the challenge that the lack of human 
capacity among the healthcare infrastructure presents to effective 
delivery of HIV/AIDS treatment, care and prevention in the focus 
countries of President Bush's historic Emergency Plan for AIDS Relief.
    We are pleased to provide the enclosed tables that provide 
additional information on the estimated numbers of physicians and 
nurses in the twelve Emergency Plan focus countries in Africa. Please 
note that some data are dated and not especially reliable. The most 
current comprehensive list of health personnel per 100,000 population 
is the database compiled by the World Health Organization's Statistical 
Information Service (WHOSIS) in 1998. Figures are from one point in 
time during any year between 1994-1998. Health personnel may be counted 
who are not practicing, i.e. Minister of Health is a medical doctor and 
counted but not practicing. We have updated several of those estimates 
for countries for which we have more recent reports from U.S. 
Government staff.
    Key findings, shown in the attached tables (for physicians and 
nurses respectively), are that:

          1. The estimated staffing of health care workers is 
        dramatically lower than the United States, in some cases 
        approximately 100-fold lower, and

          2. There is a substantial variation among the African focus 
        countries in the Emergency Plan.

    As we implement the Emergency Plan for AIDS Relief, over the next 
several months we will be working to obtain updated estimates for this 
critical element of the Emergency Plan. We will update you and others 
as these new estimates become available. As you know, under the 
Emergency Plan we are committed to developing sustainable HIV/AIDS 
healthcare networks. We recognize the limits of health resources and 
capacity in many, particularly rural, communities. To more effectively 
address that shortfall, we will build on and strengthen systems of HIV/
AIDS healthcare based on the ``network'' model. Prevention, treatment, 
and care protocols will be developed, enhanced, and promoted in concert 
with local governments and ministries of health. With interventions 
emphasizing technical assistance and training of healthcare 
professionals, healthcare workers, community-based groups, and faith-
based organizations, we will build local capacity to provide long-term, 
widespread, essential HIV/AIDS services to the maximum number of those 
in need.
    Thank you again for your continuing leadership on international 
HIV/AIDS issues and your support for the success of the Emergency Plan.

                                     Paul V. Kelly,
                                       Assistant Secretary,
                                               Legislative Affairs.

[Enclosure: As stated.]

                                           Clin.                   Lab
   Countries      Physicians    Nurses    Officer   Pharmacists   Techs
United States    279           972       ........  --            .......
Mozambique       2.6           10.7      ........  --            .......
Ethiopia         2.9           18.7      ........  --            .......
Tanzania         4.1           20.2      ........  --            .......
Rwanda           5.5           24.5      ........  --            .......
Zambia           6.9           31.2      ........  --            .......
Haiti            8.4           47.2      ........  --            .......
Cote d'Ivoire    9             47.6      ........  --            .......
Uganda           10            66.1      ........  --            .......
Kenya            13.2          84.2      ........  --            .......
Guyana           18.1          85.2      ........  --            .......
Nigeria          18.5          90.1      ........  --            .......
Botswana         23.8          113.1     ........  --            .......
Namibia          29.5          168       ........  --            .......
South Africa     56.3          471.8     ........  --            .......

    Ambassador Tobias. So in part, we are addressing this using 
a program called twinning, by matching up medical schools in 
the United States, medical centers in the United States with 
counterparts in the countries in Africa that can help them by 
loaning them people, sending residents, developing programs 
that can help in that regard. We have authorized a study that 
the Institute of Medicine is conducting to look at how we can 
best do that.
    But in the meantime, we are off and going with the first 
$350 million out the door and another $300 million coming up 
here very shortly. So I am pleased with that, and even my 
friend Bono has been very complimentary about the speed with 
which we are getting these programs going.
    Let me say a word about the drug issue because it is far 
more complicated than one might assume on the surface. Those of 
us here in the United States have come to understand what is 
meant by the term ``generic drug.'' It means that if a 
physician writes a prescription and you or I take that 
prescription to our local pharmacy and get it filled, whether 
it is filled with a generic drug or a drug that was 
manufactured by the research-based pharmaceutical company that 
originally made it, from our point of view as a patient, what 
we are going to receive is exactly, precisely, identically the 
same. It is the same because the FDA has processes to ensure 
that it is the same.
    When people describe generic AIDS drugs in Africa, they are 
not generic drugs in that context. These are drugs that are 
copies that have been manufactured by other companies without 
the same access to the data and so forth that happens when a 
drug is no longer under patent protection.
    The World Health Organization has put together a process 
that is called their prequalification list, through which they 
do a paper review of data that is provided to them under a 
confidentiality agreement by companies who wish to have their 
drugs reviewed for this list. The World Health Organization 
reviews that dossier. They make a visit to the manufacturing 
site where it is to be manufactured and they make a preliminary 
stipulation to countries who do not have regulatory processes 
that this is a list that they should look at to acquire drugs. 
There are many who believe that is good enough.
    As we gear up this program, we are going to have not only a 
lot of newcomers coming, but great risks of being sure we do 
this right. So we have been working with scientific technology 
people from the World Health Organization, from the Southern 
African Development Community, from a number of nations to try 
to determine what is the process we can use to ensure that the 
drugs we are providing for the patients in Africa are, in fact, 
safe and effective.
    Nobody wants to move this along any more quickly than I do. 
As I have said on a number of occasions, our policy is and will 
be to buy the least expensive drugs we can find from wherever 
we can find them as long as we have some reasonable assurance 
of their safety and effectiveness and we are moving ahead 
rapidly to get that kind of a process in place.
    The Chairman. I thank you.
    Mr. Natsios.
    Mr. Natsios. May I just add another subtlety to this 
discussion about treatment and care for people with HIV/AIDS?
    I think the presumption in Washington is that somewhere in 
the world where there is high incidence of HIV/AIDS is a list 
of all the people in the country that have the disease. That is 
not true. Only about 6 to 10 percent of the people who are HIV/
AIDS-positive know they have the disease because they have been 
tested. The other 90 percent have the disease and may not be at 
a stage where there is any manifestation of symptoms or they 
may have symptoms but they may not know it is HIV/AIDS. And in 
some cases, they may be later in the disease and not want to 
tell anyone they have the disease because in some areas of the 
world, if you tell people, they kill you or they will throw you 
out of the village or your house because there is a terrible 
stigma attached to being ill.
    Now, you can do a prevention program generically through 
the news media to tell people how you can prevent getting 
infected because you do not have to know who gets it or does 
not get it. You do it through the news media. But if you want 
to feed someone or you want to provide ARVs, you have to know 
individually who the person is. And 90 percent of the people 
who have the disease we do not have a list of. We do not know 
who they are and they do not know who they are.
    The Chairman. On that point, now, how do we know that that 
many people have the disease?
    Mr. Natsios. We extrapolate the data from health clinic 
surveys that are done in different countries. What will happen 
is the NGOs that have grants and contracts from the Department 
of Health and Human Services [HHS] and USAID and Randy's office 
or other countries that provide funding will go in to a 
particular health clinic and they will test everybody 
voluntarily but they will test them. And they will get a 
    The Chairman. I see.
    Mr. Natsios. And they will do this at 10 different clinics 
around the country and then they will extrapolate the data 
based on sound principles of public health.
    The Chairman. This is a sampling almost like a political 
poll in a way.
    Mr. Natsios. Exactly. I have never heard it compared that 
way, Senator, but that is a good comparison. It is the same 
principle. Yes.
    The Chairman. It is part of our craft. We do these things 
from time to time.
    Mr. Natsios. Yes. But the complication for us, until we 
have the systems set up that Randy talked about to do the 
testing, we cannot very well treat people generically. We have 
to treat people specifically. We cannot treat people as a 
group. You treat them individually. So having the health care 
infrastructure to do the testing first, then to do the 
treatment and the care is a complex area.
    In some of the areas we are working in, Senator, there are 
no roads. There are no helicopters. There are no boats to get 
to these people. They live in remote areas in villages where 
the disease has spread, but they are very inaccessible. It is 
not just that there are no doctors. There are no health 
workers. There are no clinics and there are no hospitals. So 
you have to train people on how you take the test properly, and 
then you have to train them in how you administer the drugs 
properly. Then you have to target them in order to provide the 
food aid to them.
    So it does not mean we cannot do it. We are going to do it. 
We are already doing it to a substantial degree, but it is more 
complex than it looks, which is why Randy properly said and Jim 
has said, that we have to have the absorptive capacity in place 
to absorb the resources we are directing toward this. We can do 
it. We are doing it. We are setting up the systems now, but it 
is not easy.
    The Chairman. Well, now, trace for the record, Mr. Natsios, 
since this is one of the purposes of our hearing, how USAID 
and/or the new Millennium Challenge program intersect in these 
areas. You have indicated the huge numbers of people being fed 
through the World Food Program. USAID is interested in feeding, 
and also in assisting with the treatment of HIV/AIDS. Clearly 
we have a program that Mr. Tobias is heading, but you are 
involved in this. Your people are involved in these programs.
    One of the questions that Americans have is, is there 
duplication? Do people talk to each other? Are they supporting 
each other? Do they take various specific pieces of the 
project, to avoid duplication? How would you describe the 
organized effort governmentally, given the fact that you have 
different agencies and also the United Nations involved? It is 
obviously not a United States agency, but it is backed very 
considerably by American gifts to the World Food Program.
    Mr. Natsios. The respective roles of the World Food Program 
and the NGOs and USAID and other donors are actually quite 
defined. USAID does not actually go out and physically feed 
people. We rely on our partner organizations to do that, and 
our partners, in the case of food aid, are the World Food 
Program and the NGO community and faith-based groups at the 
village level who actually go door to door and distribute 
    WFP is the wholesale distributor, which is to say if we 
have a huge program in a country, we will go to WFP and say, we 
want you to organize the national effort in x country. They 
will work with the NGOs to do the retail distribution. But in 
terms of the actual planning of the whole campaign nationally, 
WFP does that with our planning staff and then they do the 
logistical systems at the port facilities to off-load the food, 
make sure it is cared for, and it is not diverted. Then they 
put it on trucks. Their logisticians, by the way, are the best 
logisticians in the U.N. system. In fact, not just the U.N. 
system, I would say in the world. It is an excellent 
organization from a logistics and planning point of view.
    Our role is to do assessments, to determine what the need 
is, working with other organizations, to target food 
assistance, to develop the components of the food basket. In 
some societies, some food is more appropriate than others. It 
has to be nutritionally balanced. And each of us has our role. 
We have our role. WFP has its role and the NGOs have their 
role. If one of us dropped out, the system would not work. But 
there is no overlap in it. And I think it works actually in a 
very integrated way and a very efficient way. I do not know if 
you want to disagree with any of that, Jim.
    Do you have a comment, Mr. Morris?
    Mr. Morris. Senator, I agree that it works really superbly 
well, especially on the ground. It works extra-effectively as 
it relates to the HIV/AIDS issue because everyone understands 
it takes all of the ingredients to get at this. No one approach 
will solve the problem. And I think you would generally be very 
pleased to see the way that UNICEF and UNAIDS and WFP work with 
Save the Children and World Vision and the Red Cross and 
Catholic Relief and CARE, the way we work with USAID. Their 
counterpart in the UK DFID is also very good.
    Of course, the magnitude is so enormous that we are only 
getting at a piece of it, and we do not run over each other. In 
southern Africa, as Andrew said, they have come to us to manage 
the port issues so that we do not have six people competing for 
port pricing and manage the distribution on rail links or 
trucks to points where the NGOs receive the food and distribute 
it. They have the best expertise to work community by 
community. We have 1,500 partners, NGOs, 300 international, 
1,200 local, and some of the best international NGOs are 
working very hard to partner with local NGOs so that capacity 
gets stronger.
    The Chairman. Both of you have defined the fact that USAID 
and the World Food Program work on a national plan for whatever 
the country may be, and then the wholesale delivery comes from 
the World Food Program. The retail delivery comes from the 
private organizations. They carve out those spaces where they 
can be of service. Mr. Natsios has pointed out that obviously a 
hunger problem carries a different burden from HIV/AIDS. You 
have to know that you have a patient, first of all, in the case 
of HIV/AIDS, as opposed to an extrapolation of a problem. This 
may involve social stigma or even denial by politicians in high 
leadership positions in some African countries until recently. 
This creates real problems. Nevertheless, in your comprehensive 
planning, you take all this in consideration.
    How do you define how the AIDS program works with USAID? 
What are the carve-outs or responsibilities there?
    Mr. Natsios. Well, Randy is in charge and he makes the 
assignments. He allocates the budget. He sets the policies. We 
meet with him weekly; our staffs do.
    We have a global health bureau. I had a count done 
worldwide. We have 400 people working on this who are USAID 
staff people. These are not people who work for the NGOs or the 
U.N. or the ministries of health. These are USAID public health 
officers. As I said, three-quarters of our staff are in the 
field. We have USAID missions around the world. In all but one 
of the PEPFAR countries, the 14 target countries, there is a 
USAID mission. It has been there, in many cases, for many 
years. They know the networks. They know the villages. Half of 
our worldwide staff are not Americans. They are Mozambiqueans. 
They are Zambians. They are Brazilians. They are Colombians. We 
call them Foreign Service nationals [FSNs] but they are a 
critical part of our staff. Many of them are physicians or 
public health officers, and they are the ones who carry these 
programs out at the national level.
    But Randy is in charge and I have told all our staff that 
we are to take his leadership on this. We contribute, I think, 
technical expertise, research data, our networks, our 
procurement systems, our officers in the field to carry out the 
decisions that he makes.
    The Chairman. Randy.
    Ambassador Tobias. I might just add that while we have put 
together the strategy that has been submitted to the Congress 
here in Washington, the implementation of what we are doing is 
very much driven on a country-by-country basis where the U.S. 
Chief of Mission has been asked to--and they each have done a 
fine job--step up to provide integrated leadership, bringing 
together the people in USAID, CDC, and the other U.S. 
Government organizations on the ground. And that local 
orientation, I think, better enables us to coordinate the 
prevention and particularly the treatment and care aspects of 
what we are doing with other programs that are available 
through USAID or elsewhere, so that we are combining with our 
treatment and care efforts the nutrition needs and the other 
needs that are requirements of fighting this disease.
    The Chairman. You have identified another especially 
important aspect. The Chief of Mission is often our ambassador 
to the country. This gives some idea of how, in a diplomatic 
way, the State Department Secretary deals with ambassadors, 
USAID, the U.N. agency and the World Food Program. The reason I 
have tediously gone through this is that this is not well 
understood. It is the purpose of our hearing today to delineate 
the parameters more carefully so that members will have some 
idea of how this works, and that it works well. And if it does 
not work well, we will have some way of trying to get a handle 
on the problem to help you make sure that it will work better.
    I just want to ask one further question. Mr. Natsios, you 
offered very valuable testimony as the committee considered the 
Millennium Challenge idea. You were there to celebrate with the 
President yesterday the announcement of the first 16 nations 
that will be major participants in the program.
    Now, how do things change if you are a Millennium Challenge 
account, as opposed to being a normal recipient, let us say, of 
foreign aid or however we want to describe the assistance our 
country gives? Are there some new definitions of the problem?
    Mr. Natsios. The existing foreign aid program of the United 
States comes out of half a dozen spigots of money, which is 
heavily earmarked and directed by the Congress. We can debate 
whether that is useful or not, but it has a lot of specificity 
as to how we will spend the money. Population money, a $435 
million earmark, must be spent on population programs.
    The money for the Millennium Challenge Account is 
unearmarked. There are no directives. There are no earmarks by 
sector, by region, or anything else.
    The Chairman. So it goes to the State of Georgia, for 
    Mr. Natsios. That is right. The country of Georgia.
    The Chairman. Yes, the country of Georgia. Pardon me.
    Mr. Natsios. I do not want to think Atlanta is getting our 
foreign assistance program.
    The Chairman. Good point.
    Mr. Natsios. Not that they need it.
    But let us say it was the country of Georgia, which is one 
of the 16 eligible countries. The way this will work, according 
to Paul Applegarth, who is the Director of the program and is 
the CEO of the Millennium Challenge Corporation. I sit on the 
board. He will decide with his staff which countries will use 
which mechanisms for implementation. He is not going to be the 
implementing agent in the sense of actually carrying things 
out. He has said in public testimony I think before this 
committee. He said to me, can we in some countries use the 
USAID mission as the implementing agent with the ministries of 
the government in the country, and the answer is yes. Whatever 
he wants us to do, we will do.
    The Chairman. That would be their choice.
    Mr. Natsios. That is their choice.
    Now, the most important thing about the Millennium 
Challenge Corporation program, which relates directly to what 
we are talking about here, is this. There are certain things 
where there really is not a lot of international funding, for 
example, roads. The banks got out of doing roads. We got out of 
doing roads except in Afghanistan where we are doing roads. We 
do roads here and there, but there is not an enormous amount of 
funding and there are no earmarks or directives to do them.
    If you ask people in the developing world what is the most 
important thing they need in the rural areas, they need roads. 
Why is that? They cannot move. They grow extra food and it 
rots. Why? Because they cannot move it to the food-deficit 
areas. They cannot move seed in. They cannot move fertilizer 
in. They cannot move their kids to a hospital if they are sick 
or to a clinic, or they cannot move their kids easily to 
    So many countries are telling us they want this money 
invested in infrastructure. They are going to make the decision 
through the compact that they draft with the U.S. Government. 
Paul Applegarth's staff will have to approve or not approve the 
compacts. Then the board of directors will be involved in that.
    But this is country-driven, and it will be country-
implemented with some assistance from perhaps other 
institutions like USAID or OPIC or other institutions within 
the U.S. Government that might be carrying out parts of this 
    But I think what we will see is that in many cases the 
areas that they cannot get donors to give money, but they need 
desperately like infrastructure, which has been neglected for 
too long, you will see these proposals, these compacts, coming 
back heavily focused in an area. Not entirely. Some of them may 
decide they want to build school buildings and they want to 
train more teachers. That is up to them to decide. We will help 
implement it as they wish. But again, Paul Applegarth is in 
    Whatever they do with it I suspect will facilitate the work 
that all of us are doing. If they build rural roads, it is much 
easier for Randy and me to get the AIDS clinics built and the 
pharmaceuticals delivered properly, and Jim and I will have an 
easier time delivering the food assistance because there is now 
a way to get to it much more efficiently.
    One of Jim's biggest costs is trucks. Some of the roads 
that they get through now, you cannot even imagine they are 
roads that are so unbelievable. In some areas there are no 
roads whatsoever.
    So these things do work together particularly at the 
country level which is where, to put it crassly, the rubber 
meets the road.
    The Chairman. Let me indicate that reluctantly I am going 
to bring the hearing to a conclusion because the Senate is 
about to have an important rollcall vote, which hopefully will 
expedite our business on the floor.
    My colleagues, Senator Feingold and Senator Alexander, as 
our chairman and ranking member of the African Affairs 
Subcommittee, asked Mr. Morris about the Sudan and his travels 
there. To say the least, this is an extraordinarily dangerous 
situation, quite apart from a humanitarian one.
    I was impressed that five members of our committee were 
privileged to have breakfast with our Secretary of Defense, Mr. 
Rumsfeld, and General Myers this morning at the Pentagon. They 
were describing how difficult it was to either get people to 
the peace process or to extract them from the peace process, 
leaving aside the roads that Mr. Morris described that carry 
any humanitarian food, the 800,000 people, for example. The 
feat of trying to feed people in Sudan presently is prodigious. 
So is the fact that it can be done at all under these 
conditions, which are daunting even to our military as it 
attempts to bring peace.
    That is true for each of you in the work that you are 
doing. The terrain that you are covering is not easy. I 
appreciate Mr. Natsios' point that we do not do roads anymore, 
although the Millennium Challenge countries may decide we have 
to do roads in order to have the kind of delivery that we want. 
All of these are factors in the humanitarian predicament, quite 
apart from the infrastructure of the country.
    I thank each one of you very much for your forthcoming 
testimony, your statements, and your response to our questions. 
We look forward to renewing this conversation at future 
hearings when we have some more benchmarks along the road.
    With that, the hearing is adjourned.
    [Whereupon, at 12:01 p.m., the committee adjourned, to 
reconvene subject to the call of the Chair.]


              Additional Material Submitted for the Record

    [From the Los Angeles Times, May 11, 2004, Tuesday Home Edition]

       Iraq Prison Scandal; A Double Ordeal for Female Prisoners

                (By Tracy Wilkinson, Times Staff Writer)

    One woman told her attorney she was forced to disrobe in front of 
male prison guards. After much coaxing, another woman described how she 
was raped by U.S. soldiers. Then she fainted.
    A U.S. Army report on abuses at Abu Ghraib prison documented one 
case of an American guard sexually abusing a female detainee, and a 
Pentagon spokesman said Monday that 1,200 unreleased images of abuse at 
Abu Ghraib included ``inappropriate behavior of a sexual nature.''
    Whether it was one or numerous cases of rape, many Iraqis believe 
that sexual abuse of women in U.S.-run jails was rampant. As a result, 
female prisoners face grave prospects after they are released: denial, 
ostracism or even death.
    A woman who is raped brings shame on her family in the Islamic 
world. In many cases, rape victims have been killed by their relatives 
to salvage family honor, although there is no evidence this has 
happened to women who have been prisoners in Iraq.
    ``It is like being sentenced to death,'' said Sheik Mohammed Bashar 
Faydhi, a senior cleric based at Baghdad's largest Sunni mosque.
    Some Iraqi women said they were struggling to come to terms with 
the alleged abuses of female detainees at Abu Ghraib and other U.S.-
controlled lockups. Few female inmates will talk about it. Their 
lawyers lower their voices when the subject of rape comes up.
    ``I hope it's not true, because were it to be true, it is just too 
horrible to imagine,'' said Rajaa Habib Khuzaai, an obstetrician who is 
one of three women on the Iraqi Governing Council.
    This week, Khuzaai was allowed access to a detention center housing 
women--a privilege rarely granted to outsiders before the scandal.
    But female lawyers who visited the prison in March said their 
clients provided accounts of abuse and humiliation.
    To enter the prison west of Baghdad, the attorneys waded through 
dirt and coils of barbed wire, and waited for hours.
    Inside, they met with nine female detainees--four of whom, they 
said, had not been charged with any crime. U.S. military officials said 
at the time that there were 10 or 11 women being held at Abu Ghraib.
    One lawyer, Sahra Janabi, said her clients found it difficult to 
talk about their experiences in prison. Seemingly minor actions by U.S. 
soldiers, such as removing a woman's head scarf, represented a 
violation to these Muslim women.
    A prison translator was present in the meetings and took notes, 
Janabi said.
    ``We could not talk freely,'' she said. ``The women were 
devastated. They broke down crying.''
    According to Janabi, only one prisoner, a middle-aged owner of a 
cigarette stand, would speak openly, and said she did not care if the 
guards punished her.
    She told the lawyers that she had been forced to disrobe in front 
of male guards, an action that an Iraqi translator found so disgraceful 
he turned his head away in embarrassment.
    Janabi and her colleagues said many women who had been detained are 
wives or relatives of senior Baath Party officials or of suspected 
insurgents. U.S. Army officials have acknowledged detaining women in 
hopes of persuading male relatives to provide information. The lawyers 
said interrogators sometimes threatened to kill detainees.
    Dozens of people--lawyers, Iraqi officials, Iraqi and foreign human 
rights activists--have sought access to the prisons during the last 
year with minimal success. Stories of physical and sexual torture were 
rampant for much of that time. Iraqi officials and lawyers say U.S. 
military and governmental secrecy created a climate that allowed 
    Women represented a small percentage of about 40,000 detainees 
processed by U.S. authorities.
    Once the women are freed, a new trauma begins, Iraqis say.
    Khuzaai, the Governing Council member, said most female detainees 
cannot talk about what they've been through. They and their families 
try to pretend nothing ever happened, she said.
    Another lawyer, Amul Swadi, said her client fainted before 
providing further details of being raped and knifed by U.S. soldiers.
    Five former detainees described to their lawyers having been 
beaten. But they did not say they had been raped.
    ``They are very ashamed,'' Janabi said. ``They say, `We can't tell 
you. We have families. We cannot speak about what happened.' ''
    In Iraq, silence may be their best protection.
    Faydhi, the cleric, said an Iraqi man cannot acknowledge having had 
a female relative in prison. The shame, he said, is bad enough if the 
woman was in an Iraqi jail. To have been taken by the Americans 
compounds the humiliation.
    Her life may be in danger especially if the woman is from a large, 
prominent tribe, he said, and her family believes she has been raped, 
Faydhi said.
    Faydhi, an official with Iraq's Board of Islamic Clergy and a 
professor at the Islamic University, said a man will be discouraged 
from killing his female relative who has been released from prison if 
he seeks permission of an imam to restore the family's honor. But the 
cleric also said imams have limited ability to prevent this kind of 
    ``I would remind him that she is a victim, and ask, how can we 
victimize her even more? I would tell him to keep it secret, but that 
if word gets out, I would try to convince him that she should be seen 
as a patriotic symbol,'' Faydhi said. ``But it is really difficult to 
convince an Iraqi to think in such a manner.''
    Khuzaai said the stigma would be unbearable.
    ``Like any woman who is raped, there is the mental, psychological 
breakdown and everything that is related to the self,'' she said. ``But 
then there's the family and society. If a rape has happened, a family 
will never talk about it, not to the public, and maybe not even among 


                                                     26 March 2004.

Ambassador Randall Tobias
Global AIDS Coordinator,
U.S. Department of State,
Washington, DC.

    Dear Ambassador Randall Tobias,

    We, the undersigned organizations, are writing to express our 
serious concerns about efforts by the Bush administration and by your 
office to block the use of affordable generic HIV/AIDS medicines in 
U.S.-financed programs in poor countries. In order to mount a rapid and 
successful response to the growing AIDS pandemic, we call upon you to 
ensure that programs use the most affordable medicines available, and 
accept the current drug quality standards of World Health 
Organization's drug prequalification program.
    We are particularly concerned about the U.S.-initiated ``Conference 
on Fixed-Dose Combination (FDC) Drug Products: Scientific and Technical 
Issues Related to Safety, Quality, and Effectiveness,'' 29-30 March 
2004 in Gaborone, Botswana. This meeting needlessly casts doubt upon 
the clinically proven quality of generic AIDS medicines, and disregards 
the WHO's internationally recognized Drug Prequalification Program. The 
meeting is intended to justify the use of expensive, more complex 
branded treatment regimens, and will be used by the US as the minimum 
basis to justify its efforts to use bilateral assistance programs to 
lock generics out of developing countries. Of particular concern is 
your attempt to discredit the use of urgently needed fixed-dose 
combinations (FDCs) of antiretroviral AIDS medications.
    Single-pill combinations promote adherence, decrease the risk of 
resistance, and facilitate stock and procurement management, and are 
widely recognized as a core element in efforts to scale up ARV 
treatment in developing countries. FDCs are strongly preferred over 
blister packs and other multi-pill regimens. In addition to ease of use 
and other advantages, FDCs, which are taken in the form of one pill 
twice a day, are also by far the least expensive option: today, triple 
FDCs from generic manufacturers are available for less than $140 per 
person per year. The same combination from brand-name companies costs a 
minimum of $562 per person per year and must be taken in the form of 
six pills a day. Forcing people with HIV/AIDS to accept higher pill 
burdens, wasting limited taxpayer resources on brand name products, 
and, most importantly, using scarce resources to treat one person when 
the same amount of money could treat four is unacceptable.
    If the ambitious goals of the President's Emergency Plan for AIDS 
Relief (PEPFAR), and the WHO's ``3 by 5'' initiative are to be met, 
triple combination FDCs pre-qualified by WHO must be made widely 
available. FDCs are recommended in WHO treatment guidelines, and 
several generic FDCs have been certified by WHO as meeting stringent 
international standards for drug quality, safety and efficacy through 
its Prequalification Project. The WHO's standards for prequalification 
are supported by UNICEF, the World Bank, the Global Fund to Fight AIDS. 
TB, and Malaria, Columbia University's MTCT-Plus program, many national 
governments in developing countries, international humanitarian 
organizations such as Medecins Sans Frontieres (MSF), and other 
programs with experience treating people living with HIV. Clinicians in 
resource poor settings are already using triple combination generics 
with tens of thousands of patients, with efficacy and adherence rates 
equal-to-or-better than treatment success and adherence rates in the 
United States.
    Rather than disregarding the drug procurement policies of 
developing nations to create expensive new barriers that benefit US 
drug companies, your office should accept the WHO's internationally 
recognized drug quality standards and promote access to affordable 
medications. We object to any and all efforts by the Bush 
Administration and your office to block the use of WHO prequalified 
generic medications, and any efforts to discredit the standards of 
WHO's prequalification project that would impose new barriers to 
generics entering the global market.

International Organizations
International Association of Physicians in AIDS Care (IAPAC), Int'l
Partners In Health, Int'l
Oxfam International
International Council of AIDS Service Organizations (ICASO), Int'l
International Planned Parenthood Federation, Western Hemisphere Region, 
CAFOD International--Catholic Agency for Overseas Development, Int'l
AIDSETI-AIDS Empowerment & Treatment International, Int'l
Ecumenical HIV Initiative in Africa, World Council of Churches, Int'l
European AIDS Treatment Group (EATG), Int'l
Health Action International, Int'l
Health Alliance International, Int'l
ILGA--International Lesbian and Gay Association, Int'l
International Community of Women (ICW) living with HIV/AIDS, Int'l
People's Health Movement Global Secretariat, Int'l
Red Centroamericana de Personas que Viven con VIH/SIDA (REDCA+), Int'l
Third World Network, Int'l--Malaysia
African Jesuit AIDS Network, Int'l
Artists for a New South Africa, Int'l/USA-CA
Asociacion para la Salud Integral y Ciudadania de America Latina 
        (ASICAL), Int'l
COLEGA, La Federacion Espaola COLEGAS de Lesbianas, Gays, Bisexuales y 
        Transexuales, Int'l
Comite Latinoamericano y del Caribe para Defensa de los Derechos de la 
        Mujer (CLADEM), Int'l
International Health and Development Associates, Int'l
International Peoples Health Council, Int'l
INTERSECT Worldwide, Int'l
Joint Mongolian-German Reproductive Health Project, Deutsche 
        Gesellschaft fir Technische Zusammenarbeit (GTZ), Int'l
Kenya AIDS Intervention Prevention Project Group (KAIPPG) Int'l
Latin American and Caribbean Women's Health Network, (LACWHN), Int'l
Movimiento Latinoamericano y del Caribe de Mujeres Positivas (MLCM+), 
Pastoral de la Esperanza Iglesia Catolica CentroAmericana, Int'l
People's Health Movement East Africa, Int'l
Red de Salud de las Mujeres Latinoamericanas y del Caribe (RSMLAC), 
The River Fund, Int'l
Ukimwi Orphans Assistance, Int'l
Voluntary Services Overseas (VSO), Int'l
WE-ACT--Women's Equity in Access to Care & Treatment, Int'l
U.S. National Organizations
Episcopal Church USA
Presbyterian Church, USA
Unitarian Universalist Association of Congregations, USA
Amnesty International, USA
American Foundation for AIDS Research (AmFAR), USA
National Gay and Lesbian Task Force, USA
ActionAid International USA
Africa Action, USA
AIDS Treatment News, USA
AIDS Vaccine Advocacy Coalition (AVAC), USA
American Jewish World Service, USA
American Medical Students Association (AMSA), USA
Center for Health and Gender Equity (CHANGE), USA
Church Women United, USA
Commission on Social Action of Reform Judaism, USA
Consumer Project on Technology, USA
Essential Action, USA
Gay Men's Health Crisis (GMHC), USA
Global AIDS Alliance, USA
Global Exchange, USA
Health GAP (Global Access Project), USA
Jubilee USA Network, USA
Maryknoll Office for Global Concerns, USA
National Minority AIDS Council (NMAC), USA
Our Bodies Ourselves, USA
Physicians for Human Rights, USA
POZ Magazine, USA
Reformed Church in America Mission Services Program in Africa, USA
Student Global AIDS Campaign, USA
TII CANN--Title II Community AIDS National Network, USA
Treatment Action Group, USA
Washington Office on Africa, USA
Women's International League for Peace and Freedom, United States 
50 Years Is Enough: U.S. Network for Global Economic Justice, USA
Adrian Dominican Sisters, USA
Africa Faith and Justice Network, USA
AIDS Treatment Data Network, USA
The Praxis Project, USA
Corporate Responsibility Program, Province of St. Joseph of the 
        Capuchin Order, USA
Health Professional Student AIDS Advocacy Network, USA
Institute for Agriculture and Trade Policy, USA
Keep A Child Alive, USA
Maryknoll AIDS Task Force, USA
Medical Mission Sisters' Alliance for Justice, USA
Missionary Oblates, Justice/Peace & Integrity of Creation, USA
National Association for Victims of Transfusion-Acquired AIDS (NAVTA), 
Operation USA
Share International USA
South Africa Development Fund, USA
Universities Allied for Essential Medicines, USA
Foreign Country Organizations
Act Up-Paris, France
Agua Buena Human Rights Association, Costa Rica
AIDES, France
Bread for the World, Germany
Deutsche AIDS-Hilfe, Germany
Grupo de Incentivo a Vida, Brazil
Royal Tropical Institute, Holland
Treatment Action Movement, Nigeria
Action for Southern Africa (ACTSA), UK
Advancement of Rural People And Nature (ARPAN), India
African Research Institute, LaTrobe University, Australia
African Services Committee, Ethiopia
Agency for Cooperation and Research in Development (ACORD), UK
AGIHAS PLWHA Support group, Latvia
AIDS ACCESS Foundation, Thailand
AIDS Access Foundation, Thailand
AIDS Council of New South Wales (ACON), Australia
AIDS Law Unit, Legal Assistance Centre, Namibia
AIDS Task Force (HIV/AIDS Division of Africa Japan Forum), Japan
Alnaemissamtokin a Islandi, The AIDS Organization of Iceland, Iceland
Asian-Pacific Resource & Research Centre for Women (ARROW), Malaysia
Asoc. Gente Positiva (GP), Guatemala
Asociacion ACCRAD, Argentina
Asociacion Amigos de Ayacucho, Spain
Asociacion Atlacati Vivo Positivo, El Salvador
Asociacion Comunitaria Anti SIDA, Spain
Asociacion Coordinadora de Sectores de Lucha Contra el SIDA (ACSLCS), 
Asociacion Costarricense De Personas Viviendo Con VIH/SIDA, Costa Rica
Asociacion de Mujeres Contra la Violencia Intrafamiliar, Mexico
Asociacion por la Vida (ASOVIDA), Venezuela
Associcao Brasileira Interdisciplinar de AIDS (ABIA), Brazil
Associcao de apoio a pessoas corn VIH/SIDA (ABRACO), Portugal
Associcao Justica, Paz e Democracia (AJPD), Angola
Association Bondeko, France
Association de Lutte Contre le SIDA (ACLS), Morocco
Association Kenedougou Solidarite, Mali
ATTAC Japan, Japan
Australasian Society for HIV Medicine, Int'l/Australia
Australian Federation of AIDS Organisations, Australia
Australian People for Health, Education and Development Abroad 
        (international humanitarian agency of the Australian Council of 
        Trade Unions), Australia
Australian Red Cross, (Lao PDR Office), Australia
AVERT--Averting HIV and AIDS Worldwide, UK
Begin (learning & living with HIV), UK
BolivaGAY.com, Bolivia
British Columbia Persons With AIDS Society (BCPWA), Canada
Campagne pour les Droits de l'Homme au Congo (CDHC), Congo
Campaign for Improved Access to Treatment for AIDS in resource poor 
        countries (ImpAcTAIDS), Scotland
Canadian African Partnership on AIDS (CAP-AIDS), Canada
Canadian Hiv/AIDS Legal Network, Canada
Canadian Union of Public Employees (CUPE), Canada
CARE Raks Thai Foundation, Thailand
Casa del Paso del Peregrino, Argentina
CASI--ComitE d'Action Sociale et Internationale of the UniversitE de 
        MontrEal, Canada
Catholics for AIDS Prevention & Support (CAPS), UK
Center for Health and Gender Equity (CHANGE), Peru
Center for Information and Advisory Services in Health, Nicaragua
Centers of Excellence--Substance Abuse & HIV/AIDS, India
Centre for International Health (Cih) of the Macfarlane Burnet 
        institute for Medical Research and Public Health, Australia
Centro Regional de Farmacovigilancia, Argentina
Cheshire Homes, South Africa
ChildrenFIRST, South Africa
Children's Rights Centre, South Africa
Christian Health Association of Nigeria (CHAN), Nigeria
Christian Medical Association of India
CICOP Argentina
CIIEMAD/National Poytechnic Institute, Mexico
Citizen's Health Initiative, Malaysia
Coalicion ONGSIDA y de la Licda, Dominican Republic
Comite Ciudadano Anti-Sida de Castilla-La Mancha, Spain
Comite Dominicano de los Derechos Humanos CDH, Dominican Republic
Comite Orgullo Mexico
Committee of Arab and African Families United to Survive AIDS, France
Community Health Cell, India
Consultants for Health and Development, The Netherlands
Consumer Education Trust (CONSENT), Uganda
Coordinadora de AnimaciOn Socio Cultural (CASCO), Dominican Republic
Dame Una Mano, Chile
Departamento Acceso a Tratamiento Via Medidas Cautelares (DATVMC), 
        Dominican Republic
Department of Pharmacology, School of Medicine, National University of 
        La Plata, Argentina
Difaem--German Institute for Medical Mission, Germany
Discipline of Clinical Pharmacology, Faculty of Health, University of 
        Newcastle, Australia
d'Unis-Cite, France
Ecumenical Pharmaceutical Network, Kenya
EDU-PRO Foundation, Albania
Egyptian Initiative for Personal Rights, Egypt
Family Aids Caring Trust, Zimbabwe
FarmacEuticos Mundi (ONL), Spain
Farmacia Siglo XXI Foundation, Spain
Farmamundi Extremadura, Spain
Five Loaves of Bread Christian Community for Homosexuals, Hungary
Foundation For Social Concerns Inc., West Indies
Foundation for Studies and Research on Women (FEIM), Argentina
Freedom Foundation, India
Fundacion CIPRESS (Centro de Investigacion y Promocion de la Salud y la 
        Sexualidad), Chile
Fundacion Henry Ardila, Colombia
Fundacion Nimehuatzin, Nicaragua
Fundacion para el Desarrollo Humano y Social de la Region del Pueblo 
        Mam (FUNDAMAM), Guatemala
Fundacion para la Prevencion del VIH/SIDA (PRESIDA), Nicaragua
Fundacion PRESIDA, Nicaragua
Fundacion Proyecto Gente, Columbia
Fundacion Schorer, The Netherlands
Genesis Panama+
Ghana AIDS Treatment Access Group (GATAG), Ghana
Gram Bharati Samiti, India
Green Scenery, Sierra Leone
Grupo Argentino Uso Racional de Medicamentos (GAPURMED), Argentina
Grupo de apoyo de personas viviendo con VIH-SIDA (FUNDASIDA), El 
Grupo De Mujeres De La Argentina
Grupo Desde el pie, Argentina
Grupo Desida Por La Vida, Argentina
Grupo Portugues de Activistas sobre Tratamentos de VIH/SIDA (GAT), 
GTP+ grupo de Trabalhos em Prevencao Posithivo, Brazil
Health Issues Centre, Australia
Helpless Rehabilitation Society (HRS), Nepal
HIV i-Base, UK
Human Genome Analysis, Wellcome Trust Sanger Institute, UK
Imbiza Intersect Coalition, South Africa
Interact Worldwide, Int'l--UK
Interchurch Organisation for Development Cooperation (ICCO), The 
International Cooperation Area, Foundation Institut Catala de 
        Farmacologia, Spain
International Family Health, UK
International Gender Equality Network (IGEN), Hungary
Ipas Mexico A.C., Mexico
Irish Missionary Union, Ireland
Jamaica-Japan Network, Japan
Jana Arogya Andolana (PHM--Karnataka), India
Kenya AIDS Intervention Prevention Project Group (KAIPPG), Kenya
Kenya Treatment Access Movement, Kenya
KwaZulu Natal Intersect Coalition, South Africa
l'Association des Femmes Avocates au Congo (AFEAC), Congo
LGBT Organization of Venezuela
Liga Colombiana De Lucha Contra el SIDA, Columbia
Living Hope Organization, Nigeria
LOCOST (Low Cost Standard Therapeutics), India
Massive Effort Campaign, Switzerland
McGill International Health Initiative, Canada
MCS-Consult, Utrecht, The Netherlands
Misiones Diocesanas Vascas, Spain
Mulher e Saude--Centro de Referencia de Educacao em Saude da Mulher, 
Myarimar Buddhist Association of South Africa (MBASA), South Africa
National Association of People Living With HIV/AIDS (NAPWA), Australia
National Forum of People Living with HIV/AIDS Networks and 
        Organisations, Uganda
Nazareth Hospital-Holy Family Center, Kenya
Network Earth Village Japan, Japan
Network of People Living with HIV/AIDS in Nigeria (NEPWHAN), Nigeria
Network of Sex Work Projects, Int'l--Brazil
Organizacion de Apoyo a una Sexualidad Integral frente al SIDA (OASIS), 
Organization for Social Development of Unemployed, Bangladesh
Pan-African Organisation in Sweden
People Living With HIV/AIDS New South Wales, Australia
People's Health Coalition for Equitable Society, South Korea
Point of View, India
Positive Life Association of Nigeria (PLAN), Nigeria
Positive Living, Malaysia
Positive Movement, Belarus
Positive Women Victoria, Inc., Australia
Prodemur significa Promocion de la Mujer Rural, Argentina
Programa de Prevencion y Atencion a las personas afectadas por eli VIH-
        SIDA en Asturias (PAVSA), Spain
Programa de Soporte a la Autoayuda de Personas Viviendo con VIH 
        (PROSA), Peru
Progressive Organization of Gays in the Philippines (PROGAY), 
Proyecto de Vacunacion y Desarrollo Comunal de Nicaragua (PROVADENIC), 
Public Personalities Against Aids Trust, Zimbabwe
Radio Rhino International Africa, Germany
Reach Out Mbuya HIV/AIDS Initiative, Uganda
Red Argentina de Genero, Ciencia y Tecnologia (RAGCyT), Argentina
Red Colombiana de Mujeres por los Derechos Sexualers y Reproductivos, 
Red Hispana de Derechos Humanos en vih--sida y minorias sexuales, 
REDBOL, Bolivia
Regional AIDS Initiative of Southern Africa (RAISA) initiative of VSO, 
Regional Committee for the Promotion of Community Health, Nicaragua
Reproductive Health Matters, UK
Reseau des associations des PVVIH, Togo
Reseau du Burundi des PVVIH (RBP+), Burundi
RNP+ Nucleo RJ, Brazil
Salud Integral para la Mujer, A.C. (SIPAM), Mexico
SAPES Trust, Zimbabwe
Seccion Sindical de la Confederacion General del Trabajo del Ministerio 
        de Fomento, Spain
Sida Info Service, France
SIDACTION--Ensemble Contre le SIDA, France
Social Welfare Association for Men (SWAM), India
Sociedad Wills Wilde, Venezuela
Society for Women and AIDS in Africa--Cameroun (SWAA), Cameroon
Solidarite Sida, France
Southern African AIDS Information Dissemination (SAfAIDS), Zimbabwe
Spanish National Community Advisory Board (CACSIDA), Spain
Spiritia Foundation (Indonesian Peer Support Network for PLHAs), 
St. Joseph's Matale Youth Organization, Uganda
Synthesis, Greece
Tanzania Network Of Organization Of People Living With HIV/AIDS 
        (TANOPHA), Tanzania
Targeted AIDS Interventions, South Africa
Tertulia Feminist Magazine, Guatemala
Thandanani Childrens Foundation, South Africa
The Ark Foundation, Ghana
TREE, Training & Resources in Early Education, South Africa
Trocaire, Ireland
Tuyakula Group, Namibia
Uganda Coalition for Access to Essential Medicines, Uganda
UK Coalition of People Living with HIV and AIDS (UKC), UK
United Nations Association Of Uganda
University of Manitoba Medical Students' AIDS Outreach, Canada
University of Toronto International Health Program, Canada
Vanguardia Mexicana de Personas Afectadas por el VIH/SIDA (VANMPAVIH), 
Vida Positiva Quilpue, Chile
VIH/SIDA de la Iglesia Catolica de Honduras
Waverley Care Trust, Scotland
Wemos Foundation, The Netherlands
Western Cape Intersect Coalition, South Africa
Wits Pediatric HP! Working Group, South Africa
Women on Waves, The Netherlands
Women's Dignity Project, Tanzania
WTO Watch Qld, Australia
Xtending Hope Partnership, St. Francis Xavier University, Canada
Youth (OSDUY), Bangladesh
YWCA of Albania
US Local and Regional Organizations:
ACT UP Cleveland, OH
ACT UP East Bay, CA
ACT UP New York, NY
ACT UP Philadelphia, PA
ActionAIDS Philadelphia, PA
Africa Bridge, OR
African Services Committee, NY
AIDS Action Baltimore, MD
AIDS Foundation of Chicago, IL
AIDS Policy Project, PA
AIDS Survival Project, GA
Balm in Gilead, NY
Blood: Water Mission, TN
Brown University Center for AIDS Research, RI
Catholic Mission Office, Diocese of St. Cloud, MN
Citizens for Consumer Justice, PA
COLOURS Organization, PA
Concerned Medical and Health Care Professionals, MD
Drexel University (Public Health Interest Group) PHIG, PA
George Washington University Student Global AIDS Campaign, DC
God's Love We Deliver, NY
HIV Law Project, Inc, NY
Housing Works, NY
International AIDS Empowerment, TX
Liberty Research Group, NY
Loyola AIDS Awareness Coalition, MD
Lutheran Campus Ministry at the University of Arizona, AZ
Migration & Refugee Services, Diocese of Trenton, NJ
NCATA (NW Coalition for AIDS Treatment in Africa), WA
New Mexico POZ Coalition, NM
New York AIDS Coalition, NY
Office of Religion, Catholic Diocese of Scranton, PA
PA Civil Rights Initiative, PA
Pacientes de SIDA pro Politica Sana, PR
Pediatric HIV/AIDS program at The Children's Hospital of Philadelphia, 
Pennsylvania Lesbian and Gay Task Force (PLGTF), PA
Philadelphia College of Medicine Public Health Club, PA
Philadelphia International Action Center, PA
Philadelphia NORML, PA
Planet Poz, NM
Positive Health Clinic, PA
Prevention Point Philadelphia, PA
Princeton Student Global AIDS Campaign, NJ
Priority Africa Network (PAN), CA
Queers For Racial & Economic Justice, NY
Rescue Childhood, PA
Rochester Area Task Force on AIDS, NY
Rochester Global AIDS Project, NY
Sisters Mobilized for AIDS Research and Treatment (SMART University), 
Sisters of St. Joseph of Carondelet, St. Louis Province, MO
Starfish Project, New York Presbyterian Hospital, NY
Survive AIDS, CA
The Washington State Africa Network, WA
Universities Allied for Essential Medicines, University of Minnesota, 
Village Care of New York AIDS Day Treatment Program, NY
Vukani Mawethu Choir, CA
Washington Biotechnology Action Council, WA
Women's Environment and Development Organization (WEDO), NY
Yale AIDS Network, CT
Youth-Health Empowerment Project (Y-HEP), PA


             Position Statement of Catholic Relief Services

          impact of nutrition on hiv/aids affected communities
    Many communities in sub-Saharan Africa are experiencing a food 
crisis. This crisis has been accelerated by the HIV/AIDS epidemic. 
AIDS-affected households have dramatically decreased their capacity to 
maintain farms, thus they are increasingly dependent on food aid for 
survival. In the past, these communities have demonstrated resilience 
in the face of drought and poverty. The deaths of the adult members of 
these communities have created a permanent loss of valuable human 
resource that will be difficult to nearly impossible to replace.
    While we recognize the enormous benefit of the President's 
Emergency AIDS Fund, we are concerned that malnutrition will hamper our 
efforts to reduce the morbidity and mortality associated with HIV. 
Malnutrition and the concomitant infections are common health problems 
experienced by people who live in countries hardest hit by the HIV/AIDS 
epidemic. These conditions significantly compromise the immune system 
of those who are also infected with HIV, and as such, they are 
medically fragile. Nutritional deficiencies hamper immune function and, 
as such, the viral replication is accelerated. This process increases 
the rate of progression to AIDS and to death.
    People with HIV/AIDS have greater macronutrient and micronutrient 
requirements. These nutrients are required to restore the immune 
system, to improve response to (absorption of) anti-retroviral therapy, 
and to restore the muscle mass of those who experience body wasting due 
to HIV infection. It is estimated that the energy can increase by 10-
15% and protein requirements by 50% in persons living with HIV/AIDS. 
Individuals living in communities where malnutrition is endemic are 
likely to experience vitamin and mineral deficiency. While these 
deficiencies may not be clinically apparent at an early stage, their 
presence will have a direct adverse effect on one's ability to fight 
infections. Such deficiencies compound the level of immune dysfunction 
experienced by those infected with HIV. It is evident that 
micronutrients deficits will speed the progression of HIV infection to 
AIDS, and are predictive of AIDS mortality.
    Weight loss and wasting in HIV infection is due to the interaction 
of several processes:

   Decreased food intake (due to anorexia, fatigue and oral 
        diseases such as esophagitis).

   Poor absorption of nutrients (due to diarrhoea, intestinal 
        infections and intestinal abnormalities which result in 
        malabsorption of fat and vitamins).

   Metabolic alterations (there is increased energy and protein 
        requirements caused by altered production of production of 
        hormones such as glucagons, insulin, and cortisol).

    Most patients in resource-poor countries continue to present for 
care during the late stages of the HIV disease, where there is already 
severe wasting. Severe wasting requires a more complicated and 
expensive approach to restore patients to their nutritional state, and 
it may be difficult to reverse the vicious cycle of malnutrition and 
HIV disease that exists stage. These patients may benefit from high 
protein, high-energy diets, containing special supplements rich in 
vitamins and minerals. It is therefore our opinion that a more 
practical strategy, involving community food aid and early HIV 
intervention be implemented as a more cost-effective approach. Still, 
these efforts will need to be maintained and coordinated with a larger 
strategy to treat HIV/AIDS in Africa and the Caribbean.
    As antiretroviral therapy becomes increasingly available in Africa 
and the Caribbean, we must consider that inadequate diet can decrease 
the effectiveness of anti-retroviral therapy. Intestinal dysfunction in 
the malnourished, HIV-positive patient leads to reduced absorption of 
medications and hence limited effectiveness of the prescribed drug 
regimen. Many antiretroviral medications have GI side effects such as 
nausea and vomiting, that directly impact the amount of drug that is 
absorbed. Some medications require special dietary preparations to 
maximize their effectiveness, such as a full stomach. Antiretroviral 
therapy requires adherence to rigid dosing schedules to decrease the 
chances of developing drug resistance. These requirements will be 
impossible to realize in communities struggling to secure enough food 
for survival. Therefore, a successful antiretroviral program must 
consider nutritional intervention as a core component of the essential 
HIV/AIDS care package.
    Clearly, our efforts to provide emergency assistance with ART will 
not succeed without additional financial support for food distribution. 
Those communities that have struggled with high rates of malnutrition 
now have the added burden of an HIV/AIDS epidemic. We therefore believe 
that funding should be expanded to address the special nutritional 
needs of those in the early stages of the disease and those with full-
blown AIDS. Evidence proves that this will result in an enhanced 
ability to fight infection and an improved response to drug therapy.
    1. HIV/AIDS and Nutrition, SARA project, November 2000 http://
    2. Nutrition and HIV/AIDS: Nutrition Policy Paper #20 UNACC/SCN 
(2001) http://www.unsystem.org/scn/Publications/NPP/npp2O.PDF
    3. Melchior JC, Niyongabo T, Henzel D, Durack-Bowen I, Henri SC, 
Bouli A. Malnutrition and wasting, immunodepression, and chronic 
inflammation as independent predictors of survival in HIV-infected 
patients. Nutrition. 1999 15(11-12):865-9.
    4. Tang AM, Graham NM, Kirby AJ, McCall LD, Willett WC and Saah AJ. 
Dietary micronutrient intake and risk of progression to acquired 
immunodeficiency syndrome (AIDS) in human immunodeficiency virus type I 
(HIV-1)--infected homosexual men. Am J. Epi 1993 138(11):937-951.
    5. Tang AM, Graham NM, and Saah AJ. Effects of micronutrient intake 
on survival in human immunodeficiency virus type I infection. Am J Epi 
1996 143(12):1244-56.

  Food Aid and HIV/AIDS Programming: Lessons from CRS Field Experience

      nutritional and food security issues where aids is prevalent
Nutritional Issues
   Food insecurity increases vulnerability to HIV/AIDS--
        physiologically and behaviorally (zinc, vitamin A deficiencies 
        increase risk of STDs; iron deficiency reduces resistance to 
        disease; harmful coping strategies to address food insecurity 
        result in increased exposure to HIV).

   HIV/AIDS increases food insecurity and poor nutrition 
        (illness, demands of care-giving reduce production and cash; 
        health care costs cause HH to eat fewer meals of lower quality 

   People with HIV/AIDS have greater macronutrient and 
        micronutrient requirements (more Kcal, protein, 

   Poor nutrition speeds progression of HIV/AIDS.

   Inadequate diet can decrease effectiveness of anti-
        retroviral (ARV) treatment--affects absorption, metabolism, 
        distribution or excretion of the drugs.

   ARV therapy can increase nutrient tosses and affect food 
Other Food Security Issues
   AIDS attacks the most productive segment of the population. 
        One result: reduced labor for farm work--in Ethiopia one study 
        found that households spend between 1/2 and 2/3 less time on 
        agriculture than households not directly affected by HIV/AIDS. 
        Programs must work with communities to develop alternative 
        production that is less labor-intensive, produces more 
        nutritious and more high-value crops, located closer to family 
        homes and carried out on a scale that can be managed by 

   As productive adults become ill and die, there are fewer 
        teachers for schools, few staff to provide government services, 
        so new approaches are needed to fill the gaps. Support for 
        community-based foster care and for alternatives to government 
        service provision are essential. Building capacity of local 
        community organizations becomes critical.

   Orphaned children have no parents to teach them how to 
        become productive adults. Programs must help communities 
        develop new family structures, and new ways to transfer 
        livelihood knowledge to the next generation. Comprehensive 
        programs must provide children and youth with life skills as 
        well as marketable skills. Affected families have often lost 
        all assets to medical and funeral bills. Approaches to 
        rebuilding food security need to address the broader livelihood 
        security concerns as well, developing assets that will protect 
        and support children both now and in the future.
    how current hiv/aids programming mechanisms address these issues
    One major issue with HIV/AIDS funding is that much of it is 
currently stove-piped. ARV funding is for drugs. OVC funding is for 
orphans and vulnerable children. Palliative care funding will be for 
home-based and community-based care. . . . There is no clearly 
identified mechanism for promoting the integration of funding and other 
resource streams that the complex responses on the ground require. 
Addressing HIV/AIDS at the community level requires coordination and 
program design that will ensure the multiple needs of affected 
communities are met. Otherwise, funds spent for ARV therapy without 
incorporation of appropriate food and nutrition is not only wasted, but 
also detrimental due to increased drug resistance. Provision of drugs 
and food to affected adults doesn't meet the current and future needs 
of their children.
             how food aid programs can address these issues
    Increased availability of and access to micronutrient-fortified 
food is needed to

   decrease transmission of HIV,

   reduce progression of the disease in those living with HIV

   reduce mother to child transmission and improve health of 
        children born to HIV+ mothers

   increase effectiveness of ARV therapy

                      HIV/AIDS & Food Programming

                                May 2004

    CRS is invoWed in state-of-the-art and innovative programs targeted 
at reducing food insecurity among those affected and infected by HIV/
AIDS in various regions in Africa, Latin America and Asia. Below are 
examples of current CRS food security and HIV/AIDS programs.

Project LISTEN (Livelihood Strategies Eliminating Needs)
Countries: Malawi and Zambia (FY 2004)
Program Area: HIV/AIDS, Food Security, Integral Human Development
Total Cost: $556,890
Total Beneficiaries: 21,500
    Project LISTEN complements existing food aid programs in Malawi and 
Zambia by stimulating agriculture production as a short-term 
intervention while also building the capacity in 30 communities to 
mitigate risk in the long-term. The community resilience approach of 
Project LISTEN helps households adapt positive coping strategies to 
shocks by analyzing existing assets and resources that households can 
access to improve their livelihoods. Project LISTEN complements 
existing developmental relief and recovery programs, namely C-SAFE and 
JEFAP II, which are necessary in helping communities recover and 
rebuild assets lost due to shocks.
Title II PL 480 Development Assistant Program
Country: Ghana (FY 2004-2008)
Program Area: Nutrition, Safety Net, HIV/AIDS, TB DOTS
Total Cost: $19,523,227
Total Beneficiaries: 427,601
    The safety net portion of the program targets 15,000 vulnerable 
persons throughout Ghana each year. Primary beneficiaries include 
individuals infected with or affected by HIV/AIDS, TB patients, and 
orphans. Working through the Christian Health Association of Ghana, the 
Ghana National Association of People Living with HIV/AIDS, and MOH TB/
AIDS wards, CRS/Ghana provides wet rations to institutionalized HIV/
AIDS and TB patients, home-based People Living with AIDS, and those 
under the Directly Observed Therapy program. Take home rations are 
designed to supplement daily intakes and will provide 20 percent of the 
caloric requirements of an average Northern Ghanaian family. For TB 
patients, food assistance will provide needed nutritional support 
during the time of recovery, and provide an incentive to patients to 
comply with the DOTS regimen.
St. Joseph's Catholic Youth Group HIV/AIDS ``Siyakekela'' Youth Support 
Country: South Africa (FY 2002-2004)
Program Area: Life skills, Food and other support, Youth affected by 
Total Cost: $9,796
Total Beneficiaries: 2,500
    The Community Outreach Center at St. Mary's Hospital runs an HIV/
AIDS Community support program that offers counseling services and 
support. In the past, services at this center were designed for adults. 
This program is geared toward children affected by HIV/AIDS between the 
ages of seven and eighteen. A youth group has been formed and trainings 
have been given on taking care of themselves and those ill at home. In 
addition to these awareness campaigns and trainings, psychological and 
material support (i.e. nutritional support) are included as part of the 
comprehensive package. Life skills are also promoted through business 
and computer skill building as a component of the youth group.

                            Coalition for Food Aid,
                           1201 F Street, N.W., Suite 1100,
                                    Washington, DC, April 27, 2004.

The Honorable Richard G. Lugar, Chairman
Senate Committee on Foreign Relations,
United States Senate,
Washington, DC 20010.

    Dear Chairman Lugar:

    The Coalition for Food Aid welcomes the opportunity to submit this 
letter and attached information for the record for the May 11, 2004 
hearing on HIV/AIDS and hunger. The Coalition is comprised of sixteen 
US private voluntary organizations and cooperatives (jointly referred 
to as ``PVOs'') that conduct food aid programs overseas to improve the 
health, living conditions and incomes of millions of people who live in 
poverty and suffer from hunger. All of the members do much more than 
deliver food--they implement developmental and relief programs in 
cooperation with local communities, governments and organizations.
    Food aid is the expression of American goodwill through ``people-
to-people'' programs. American farmers produce the food, American 
businesses process, package and transport the food, and American PVOs 
make sure it is used effectively to help people in need. US food aid 
programs have great reach and impact among the poor and 
disenfranchised, helping people overcome despair and improving people's 
lives. The PL 480 Title II program, which focuses on food security 
needs of vulnerable populations, is the largest US food aid program and 
PVOs are the primary partners for the implementation of Title II 
developmental programs.
    Nutrition and food security are critical and integral issues to 
address in the HIV/AIDS pandemic. Since US Government HIV/AIDS funds 
focus on particular treatment, care and prevention goals, PVOs find 
that it is necessary to identify other sources of funds to address 
nutritional and food security needs. They raise private funds and in 
some cases are able to use PL 480 Title II resources for these 
purposes, as explained in the attachments. However, much more could be 
done to expand the amount of funding available under Title II for HIV/
AIDS and to make it easier to integrate food and cash resources.
    If Title II was administered as intended by law, the United States 
could provide additional assistance to help people who suffer from 
chronic hunger, which is greatly needed in communities with high 
prevalence of HIV/AIDS. Many communities that had promise 10 years ago 
are falling behind today because of the HIV/AIDS pandemic. Income-
earners in the community who are infected become weak and many die, 
family incomes plummet, agricultural fields lie fallow, children often 
quit school to work or care for siblings, and extended families that 
serve as caregivers fall into poverty. Poor diets hurt many in the 
community, and children and people living with HIV/AIDS are 
particularly vulnerable. PVOs are ready to expand Title II nutritional 
and food security programming for HIV/AIDS-affected communities. This 
disease threatens people's lives as much as any emergency.
    Attached are illustrative examples of how PVO food aid programs are 
used to address special needs dues to the prevalence of HIV/AIDS.
    Of the funds appropriated for Title II, more must be used to expand 
non-emergency programs from 1,000,000 metric tons to the 1,875,000 
metric ton statutory level in order to address chronic hunger. PL 480 
Title II requires 1,875,000 metric tons of food aid to be provided for 
non-emergency programs each fiscal year in order to reduce chronic 
hunger. Despite this mandate, in FY 2004, we expect only 1,000,000 
metric tons of Title II will be used for non-emergency programs--about 
half of the minimum requirement. Yet, chronic needs are growing due to 
the prevalence HIV/AIDS and other chronic diseases and setbacks caused 
by natural disasters, civil strife and economic downturns. Currently, 
the Office of Management and Budget (OMB) is seeking both to limit the 
amount of tonnage used for these programs and to cutback program 
duration from five-years to three-years, even though studies have shown 
that five-year programs are more effective.
    Addressing nutritional and food security problems associated with 
HIV/AIDS and helping communities that are prone to emergencies are two 
tangible examples of the types of non-emergency programs that need to 
be expanded. These programs would be in addition to current Title II 
non-emergency programs that have proven results in poor communities, 
such as increasing agricultural productivity and diversifying 
production, decreasing chronic under-nutrition among children, and 
improving the nutritional status of women.
    It is important to have adequate funds for emergencies, but Title 
II was not intended to be an emergency reserve. Instead, the Bill 
Emerson Humanitarian Trust Act provides contingency funds and 
commodities for emergencies. The BEHT can be tapped before USAID cuts 
into the 1,875,000 metric tons of Title II commodities available for 
non-emergency programs.
    In this time of international stress, US assistance programs 
conducted by PVOs directly show America's care and compassion to people 
in developing countries. PVOs are supported by Americans through 
private contributions, which cover general operations and enable them 
to have a strong presence in many developing countries. However, 
private donations cannot supply the level of funding needed for 
procuring, transporting, implementing, monitoring and administering 
food aid programs. Thus, US Government funding for food aid is 
critical. PVOs provide expertise in program development and 
implementation; transparency and accountability for the use of US 
Government resources; strengthen the management capabilities of local 
institutions so efforts can be sustained; provide a network of local 
contacts and relationships; and encourage entrepreneurship and private 
sector development.
    Mr. Chairman, we appreciate the opportunity to submit these 
comments and the attached information on HIV/AIDS programs and hunger. 
Thank you very much for helping to assure that the US response to HIV/
AIDS is comprehensive and field-driven, seeking solutions within 
affected communities and supporting the implementation of successful 
strategies for long-term impact. We would be pleased to answer any 
questions you may have.

                     Ellen S. Levinson, Executive Director.



    The first column shows how food rations can be used. Because food 
aid must be integrated with other activities to have a long-term 
impact, the second column describes the types of complementary 
activities that would be funded through monetization or from other 

                                      Activities Funded by Monetization
        Food is Provided as:                  or Other Sources:
 An incentive for people to   HIV/AIDS prevention
 receive HIV/AIDS testing and         education programs conducted by
 counseling.                          community-based organizations and
                                      health facilities.
 Part of home-based care      Training village health
 for people living with HIV/AIDS      workers and caregivers in home-
 and their families.                  based care and support, including
                                      preventing mother-to-child
                                      transmission of HIV/AIDS.
 Part of community-based      Care and support of
 nutrition programs, i.e. to meet     orphans and vulnerable children,
 the nutritional needs of people      i.e. providing school fees and
 living with HIV/AIDS, people         child care for younger siblings so
 receiving anti-retroviral            school-aged children can attend
 treatment, and orphans and           class and providing access to
 vulnerable children.                 psychosocial counseling, health
                                      care and social services.
 An incentive to              Training and support for
 participate in agricultural and      the implementation of community-
 work programs that increase family   based nutrition, education,
 incomes and assets and improve       agricultural and work programs.
 community infrastructure.
 An incentive for             Coordination with HIV/AIDS
 participation in treatment           service providers to increase
 programs for TB patients.            access to critical services, such
                                      as voluntary testing and
                                      counseling, medical care and
                                      social services.