[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]




 
  HIV PREVENTION: HOW EFFECTIVE IS THE PRESIDENT'S EMERGENCY PLAN FOR 
                          AIDS RELIEF [PEPFAR]

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

                                HEARING

                               before the

                   SUBCOMMITTEE ON NATIONAL SECURITY,
                  EMERGING THREATS, AND INTERNATIONAL
                               RELATIONS

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 6, 2006

                               __________

                           Serial No. 109-239

                               __________

       Printed for the use of the Committee on Government Reform


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                     COMMITTEE ON GOVERNMENT REFORM

                     TOM DAVIS, Virginia, Chairman
CHRISTOPHER SHAYS, Connecticut       HENRY A. WAXMAN, California
DAN BURTON, Indiana                  TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
GIL GUTKNECHT, Minnesota             CAROLYN B. MALONEY, New York
MARK E. SOUDER, Indiana              ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio           DENNIS J. KUCINICH, Ohio
TODD RUSSELL PLATTS, Pennsylvania    DANNY K. DAVIS, Illinois
CHRIS CANNON, Utah                   WM. LACY CLAY, Missouri
JOHN J. DUNCAN, Jr., Tennessee       DIANE E. WATSON, California
CANDICE S. MILLER, Michigan          STEPHEN F. LYNCH, Massachusetts
MICHAEL R. TURNER, Ohio              CHRIS VAN HOLLEN, Maryland
DARRELL E. ISSA, California          LINDA T. SANCHEZ, California
JON C. PORTER, Nevada                C.A. DUTCH RUPPERSBERGER, Maryland
KENNY MARCHANT, Texas                BRIAN HIGGINS, New York
LYNN A. WESTMORELAND, Georgia        ELEANOR HOLMES NORTON, District of 
PATRICK T. McHENRY, North Carolina       Columbia
CHARLES W. DENT, Pennsylvania                    ------
VIRGINIA FOXX, North Carolina        BERNARD SANDERS, Vermont 
JEAN SCHMIDT, Ohio                       (Independent)
BRIAN P. BILBRAY, California

                      David Marin, Staff Director
                Lawrence Halloran, Deputy Staff Director
                      Benjamin Chance, Chief Clerk
          Phil Barnett, Minority Chief of Staff/Chief Counsel

Subcommittee on National Security, Emerging Threats, and International 
                               Relations

                CHRISTOPHER SHAYS, Connecticut, Chairman
KENNY MARCHANT, Texas                DENNIS J. KUCINICH, Ohio
DAN BURTON, Indiana                  TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         BERNARD SANDERS, Vermont
JOHN M. McHUGH, New York             CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio           CHRIS VAN HOLLEN, Maryland
TODD RUSSELL PLATTS, Pennsylvania    LINDA T. SANCHEZ, California
JOHN J. DUNCAN, Jr., Tennessee       C.A. DUTCH RUPPERSBERGER, Maryland
MICHAEL R. TURNER, Ohio              STEPHEN F. LYNCH, Massachusetts
JON C. PORTER, Nevada                BRIAN HIGGINS, New York
CHARLES W. DENT, Pennsylvania

                               Ex Officio

TOM DAVIS, Virginia                  HENRY A. WAXMAN, California
                  R. Nicholas Palarino, Staff Director
                 Beth Daniel, Professional Staff Member
                        Robert A. Briggs, Clerk
             Andrew Su, Minority Professional Staff Member


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on September 6, 2006................................     1
Statement of:
    Dybul, Mark R., U.S. Global AIDS Coordinator, U.S. Department 
      of State; and Kent Hill, Assistant Administrator, Bureau 
      for Global Health, U.S. Agency for International 
      Development................................................    16
        Dybul, Mark R............................................    16
        Hill, Kent...............................................    27
    Gootnick, David, Director, International Affairs and Trade, 
      Government Accountability Office; Helene Gayle, president 
      and chief executive officer, Care USA; Lucy Sawere Nkya, 
      member of Tanzanian Parliament (MP, Women Special Seats), 
      medical chairperson, Medical Board of St. Mary's Hospital 
      Morogoro, director, Faraja Trust Fund; and Edward C. Green, 
      senior research scientist, Harvard Center for Population 
      and Development Studies....................................    57
        Gayle, Helene............................................    85
        Green, Edward C..........................................   119
        Gootnick, David..........................................    57
        Nkya, Lucy Sawere........................................   111
Letters, statements, etc., submitted for the record by:
    Dybul, Mark R., U.S. Global AIDS Coordinator, U.S. Department 
      of State, prepared statement of............................    21
    Gayle, Helene, president and chief executive officer, Care 
      USA, prepared statement of.................................    89
    Gootnick, David, Director, International Affairs and Trade, 
      Government Accountability Office, prepared statement of....    60
    Green, Edward C., senior research scientist, Harvard Center 
      for Population and Development Studies, prepared statement 
      of.........................................................   122
    Hill, Kent, Assistant Administrator, Bureau for Global 
      Health, U.S. Agency for International Development, prepared 
      statement of...............................................    30
    Kucinich, Hon. Dennis J., a Representative in Congress from 
      the State of Ohio, prepared statement of...................   143
    Lee, Hon. Barbara, a Representative in Congress from the 
      State of California, prepared statement of.................    55
    Nkya, Lucy Sawere, member of Tanzanian Parliament (MP, Women 
      Special Seats), medical chairperson, Medical Board of St. 
      Mary's Hospital Morogoro, director, Faraja Trust Fund, 
      prepared statement of......................................   115
    Shays, Hon. Christopher, a Representative in Congress from 
      the State of Connecticut, prepared statement of............     3
    Waxman, Hon. Henry A., a Representative in Congress from the 
      State of California, prepared statement of.................     8


  HIV PREVENTION: HOW EFFECTIVE IS THE PRESIDENT'S EMERGENCY PLAN FOR 
                          AIDS RELIEF [PEPFAR]

                              ----------                              


                      WEDNESDAY, SEPTEMBER 6, 2006

                  House of Representatives,
       Subcommittee on National Security, Emerging 
              Threats, and International Relations,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 1:07 p.m., in 
room 2154, Rayburn House Office Building, Hon. Christopher 
Shays (chairman of the subcommittee) presiding.
    Present: Representatives Shays, Duncan, and Waxman (ex 
officio).
    Staff present: Beth Daniel, professional staff member; 
Nicholas R. Palarino, Ph.D., staff director; Robert Briggs, 
analyst; Naomi Seller, minority counsel; Andrew Su, minority 
professional staff member; Earley Green, minority chief clerk; 
and Jean Gosa, minority assistant clerk.
    Mr. Shays. A quorum being present, the Subcommittee on 
National Security, Emerging Threats, and International 
Relations hearing entitled, ``HIV Prevention: How Effective is 
the President's Emergency Plan for AIDS Relief [PEPFAR]'' is 
called to order.
    In 1981, scientists diagnosed the first cases of the 
disease we now call HIV/AIDS, Human Immunodeficiency Virus/
Acquired Immune Deficiency Syndrome. Today, 25 years later, 
nearly 40 million people live with HIV/AIDS. Worldwide last 
year, 4.1 million people were newly infected with HIV, and 2.8 
million people died from AIDS, of whom 570,000 were children. A 
third of these deaths occurred in Sub-Saharan Africa.
    A January 2000 U.S. Central Intelligence Agency National 
Intelligence Estimate warns HIV/AIDS could deplete a quarter of 
the populations of certain countries. There is no cure for the 
disease.
    The United States has committed massive amounts of foreign 
assistance to fight HIV/AIDS. After Congress passed the 
Leadership Act of 2003, President Bush announced a $15 billion, 
5-year initiative known as PEPFAR, the President's Emergency 
Plan for AIDS Relief. PEPFAR fights HIV/AIDS through 
initiatives in prevention, treatment and care.
    By 2010, the goal of PEPFAR is to prevent 7 million new 
infections, support treatment for 2 million HIV-infected people 
and provide care for 10 million people affected by HIV/AIDS, 
including orphans and vulnerable children. Multiple branches of 
the U.S. Government are engaged in this vast effort, including 
the Department of State, U.S. Agency for International 
Development, Health and Human Services, the Department of 
Defense, and the Peace Corps.
    PEPFAR assistance will eventually reach 120 countries, but 
concentrates the bulk of its funds in 15 hardest hit focus 
countries, most of which are in Sub-Saharan Africa.
    Today, we examine PEPFAR's prevention component. The 2003 
Leadership Act, which authorized PEPFAR, recommended and now 
requires 20 percent of total PEPFAR funds be spent on HIV 
prevention. The act endorses HIV sexual transmission prevention 
through the model for Abstinence, Being Faithful and Correct 
and Consistent Use of Condoms, known for short as ABC, and 
includes a spending requirement that one-third of prevention 
funds go to abstinence-until-marriage initiatives. This 
spending requirement has come under intense scrutiny as a 
conservative political vehicle rather than a scientifically 
based policy.
    Supporters of ABC contend it is evidence based and shows 
promising results. Critics assert the spending requirement is 
an arbitrary figure that ignores human nature and hinders local 
ability to respond to the epidemic appropriately in each 
different country. Others argue the key is integration of 
different prevention methods to create comprehensive 
initiatives that reach as many as possible, as effectively as 
possible, and flexibility so local implementers can respond to 
the specific conditions where they work.
    This June, I joined Congresswoman Barbara Lee and others in 
introducing the Protection Against Transmission of HIV for 
Women and Youth, referred to as PATHWAY, Act of 2006, which 
includes a provision to lift the abstinence-until-marriage 
funding earmark from PEPFAR.
    Our witnesses today represent a broad spectrum of opinion 
and world-class expertise in their respective fields. We 
welcome Ambassador Mark Dybul, Global AIDS Coordinator at the 
Department of State, and the Honorable Kent Hill, head of 
Global Health at the U.S. Agency for International Development.
    We also welcome our second panel, including Dr. David 
Gootnick of the Government Accountability Office, Dr. Helene 
Gayle from CARE USA, Dr. Edward Green from Harvard University, 
and a special welcome to Dr. Lucy Sawere Nkya, a member of 
Parliament from Tanzania and a long time luminary in HIV/AIDS 
work. I will just say she's one of the most impressive persons 
I have ever met.
    HIV/AIDS is a pandemic that has produced consequences 
unimaginable 25 years ago. Today, we need to imagine that we 
can conquer this disease. The world needs PEPFAR and other 
programs like it to fight HIV/AIDS. We must make sure our 
funding is responsive, and that the money is being used 
sustainably and wisely.
    That concludes my statement. At this time I would call on 
Mr. Waxman, the ranking member of the full committee.
    [The prepared statement of Hon. Christopher Shays follows:]

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    Mr. Waxman. Thank you very much, Mr. Chairman.
    We're here to discuss the progress of prevention programs 
under the U.S. Global AIDS Program, and I want to thank the 
chairman for holding this important hearing, and for all of our 
witnesses for coming here to share their experience and 
expertise.
    The President's Emergency Plan for AIDS Relief has made 
important progress in some areas. In particular, U.S. 
assistance has helped bring the number of people getting 
treatment in the 15 focus countries from a few thousand to over 
1 million. I applaud the work of Dr. Dybul and Mr. Hill and all 
of the in-country staff contributing to this effort.
    But worldwide, for each person who gained access to HIV 
treatment last year, seven more people became infected with 
HIV. There is no way for the pace of treatment access to keep 
up with that rate of new infections.
    So as we pass the halfway point of this first 5 years of 
this program, it's time that Congress take a serious look at 
prevention. We need to examine what's working and what isn't. 
We need to identify programs that are most effective in 
reducing vulnerabilities and risk behaviors, and we need to 
figure out why they work and where they work, and we need to 
replicate the most successful ones.
    Today, we're going to look in particular at the results of 
a GAO investigation into one element of U.S. HIV prevention 
policy. It's the requirement that one-third of prevention funds 
be spent on Abstinence and Be Faithful programs. When the House 
debated the abstinence requirements, the focus of the debate 
was the proper balance of abstinence funding, be-faithful 
funding and condom funding to stop the transmission of HIV.
    As depicted in the chart, we had a debate over whether one-
third of the funds should be designated for abstinence or if 
instead we should let the experts determine the right balance. 
Like several of my colleagues, I felt strongly that we should 
let the experts decide. But what the GAO report makes clear is 
that we weren't discussing the right pie, we were focused on 
three interventions that address sexual transmission. And the 
behavior changes these programs tried to create, delayed sexual 
debut, partner reduction and condom use, are crucial elements 
of HIV prevention, but we didn't discuss all of the other 
elements of prevention. We didn't talk about antiretroviral 
therapy to reduce mother-to-child transmission. We didn't talk 
about blood supply safety. We didn't talk about the medical 
injection safety. We didn't talk about programs that address 
the myriad social problems that render people vulnerable to HIV 
infection. And we didn't talk about the possibility of new 
types of interventions like male circumcision.
    When we look at the full picture, as shown in this second 
chart, a few things are much clearer. First, when we say that 
one-third of prevention funds have to go to abstinence 
programs, we cut into many other types of prevention programs. 
The administration has determined that the be-faithful message 
is linked to the abstinence message, and as reported to us, the 
programs that cover both abstinence and faithfulness will be 
counted toward the one-third requirement.
    But other interventions, like those that save the lives of 
babies born to women with HIV, have to compete for the rest of 
the prevention funds. As GAO found, countries have had to 
restrict funding for many other kinds of prevention programs to 
meet the abstinence requirement.
    What's also clear from this chart is that HIV prevention is 
extremely complicated. There is no question that determining 
the right mix for any given country requires an enormous amount 
of time and expertise. No formula that we try to write in 
Congress will ever be right for the epidemiology and culture of 
each country.
    It's difficult to overstate the role of the USAIDS program. 
We are the biggest donor of the world. Our policies carry great 
weight and very strong sway over countries and individual 
grantees. We must not shrug off the responsibility we have to 
pursue the best evidence-based prevention policies.
    So it's time for us to stop focusing on arbitrary 
formulations and have a meaningful discussion of U.S. 
prevention policy that extends beyond ideology and rhetoric and 
domestic politics, and I hope we can start this debate today.
    Thank you very much.
    [The prepared statement of Hon. Henry A. Waxman follows:]

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    Mr. Shays. I thank the gentleman.
    At this time, Mr. Duncan.
    Mr. Duncan. I have no statement, Mr. Chairman, but I do 
think this is a very important topic, and I'm pleased that you 
would call a hearing in a continuation of many important 
hearings in your subcommittee. Thank you very much.
    Mr. Shays. I thank the gentleman very much.
    Let me take care of some business before calling on our 
first panel.
    I ask unanimous consent that all members of the 
subcommittee be permitted to place an opening statement in the 
record and that the record remain open for 3 days for that 
purpose, and without objection, so ordered.
    I ask future unanimous consent that all witnesses be 
permitted to include their written statements in the record, 
and without objection, so ordered.
    And at this time the Chair would acknowledge our first 
panel. We have Ambassador Mark Dybul, U.S. Global AIDS 
Coordinator, U.S. Department of State, and the Honorable Kent 
Hill, Assistant Administrator, Bureau for Global Health, U.S. 
Agency for International Development. And as you gentlemen 
know, we swear in all of our witnesses, and if you will just 
stand, I'll swear you in.
    [Witnesses sworn.]
    Mr. Shays. I'll note for the record that both of our 
witnesses have responded in the affirmative.
    It's truly an honor to have both of you here. You are real 
experts doing very important work. And I know the committee 
welcomes you and looks forward to the dialog that we'll have.
    At this time, Mr. Dybul--Ambassador, excuse me--we'll ask 
you to make an opening statement. What we do with the clock, we 
have 5 minutes, but we roll it over another 5 minutes. So we'll 
ask you not to be more than 10, but somewhere in between 5 and 
10 would be helpful.
    Thank you.

STATEMENTS OF MARK R. DYBUL, U.S. GLOBAL AIDS COORDINATOR, U.S. 
 DEPARTMENT OF STATE; AND KENT HILL, ASSISTANT ADMINISTRATOR, 
    BUREAU FOR GLOBAL HEALTH, U.S. AGENCY FOR INTERNATIONAL 
                          DEVELOPMENT

                   STATEMENT OF MARK R. DYBUL

    Ambassador Dybul. Thank you, Mr. Chairman, Congressman 
Waxman, and Congressman Duncan. Thank you for this opportunity 
to discuss President Bush's unprecedented emergency plan for 
AIDS relief. We've been grateful for the strong bipartisan 
support of Congress, including members of this subcommittee.
    I'm pleased to be here with Dr. Hill, who leads the U.S. 
Agency for International Development work toimplement PEPFAR.
    Fundamentally, it's the generosity of the American people 
that has created the largest international health initiative in 
history dedicated to a specific disease.
    In looking at just 15 focus countries of the more than 120 
countries where we have worked through bilateral programs in 
the first 2 years of the Emergency Plan, we've seen remarkable 
results to date, as both the chairman and Mr. Waxman have 
noticed. We supported treatment for over 560,000 people, 61 
percent of whom are women, and 8 percent of whom are children. 
We have supported care for 3 million, including 1.2 million 
orphans and vulnerable children. We've supported counseling and 
testing for 13.6 million, 69 percent of whom are female.
    And these figures do not include work in other countries 
with bilateral U.S. Government programs under the Emergency 
Plan. More importantly, the American people's support for the 
programs of the Global Fund to Fight Aids, Tuberculosis and 
Malaria, other bilateral programs and the Global Fund are 
integral components of PEPFAR.
    Yet as was noted, treatment and care for those already 
infected with HIV/AIDS are not enough. If we do not slow the 
rate of infections, it will be impossible to sustain the 
resources, financial, human, institutional, for care and 
treatment of an ever expanding pool of infected individuals. 
Ultimately, effective prevention is the only way to achieve the 
elusive goal of an AIDS free generation.
    More than 3\1/2\ years ago, President Bush had the vision 
to insist that prevention, treatment and care be addressed 
together, an idea that now commands wide respect. The lessons 
learned from the Emergency Plan are now helping to fuel 
transformation of the HIV/AIDS responses in nations around the 
world.
    PEPFAR's unparalleled financial commitment has permitted 
the U.S. Government to support a balanced, multi-dimensional 
approach, one that was not possible at pre-PEPFAR funding 
levels. The total annual spending on HIV/AIDS prevention as 
well as treatment and care has continually increased since the 
passage of the Leadership Act.
    If Congress enacts the President's request for $4 billion 
for HIV/AIDS in 2007, that will be the fourth straight year of 
increased funding under the President's plan. In comparison 
with the fiscal year 2001 total of $840 million for global HIV/
AIDS, these PEPFAR funding levels represent a quantum leap.
    Even with the massive and highly successful scale-up of 
treatment and care services with PEPFAR support, PEPFAR 
preventionfunding in the focus countries has grown 
substantially from 2004 to 2006, yet there has been a 
significant constraint on resources in the focus countries, as 
was noted in the GAO report. Almost $527 million from focus 
country programs has been redirected to the Global Fund, and 
other components of the Emergency Plan over PEPFAR's first 3 
years.
    The effectiveof this trend has been to force country teams 
to make difficult tradeoffs. In 2007 and beyond, full funding 
for focus country activities is essential if PEPFAR is to meet 
its 2-7-10 goals, including the prevention goal.
    If I accomplish nothing else today, I hope I will be able 
to persuade you of the importance of full funding, meeting the 
President's request for the focus countries to ensure effective 
prevention.
    Now if I could, I'd like to turn briefly to what 
constitutes effective prevention.
    As Mr. Waxman noted, PEPFAR--and effective prevention is a 
complicated matter. PEPFAR supports the most comprehensive 
prevention strategy in the world, including interventions for 
sexual transmission, prevention of mother-to-child 
transmission, safe blood, safe medical injections, all the 
pieces of the pie that are up there. However, prevention must 
squarely address the reality that the overwhelming majority of 
cases of HIV/AIDS infection are due to sexual activity, 80 
percent worldwide.
    Effective prevention must address risky sexual behavior 
because it is the heart of this epidemic.
    The people of Africa have been leaders in developing a 
prevention strategy that responds to the special challenges 
that they face, the ABC approach, which stands for Abstinence, 
Being Faithful and Correct and Consistent Use of Condoms. In 
fact, the strategies of many nations in Africa and elsewhere 
included the ABC approach, delivered in culturally sensitive 
ways, long before the advent of the Emergency Plan.
    The past year has been a particularly important moment in 
the effort for sustainable development. Impressive new 
demographic health survey evidence from a growing number of 
nations is expanding the evidence base for the ABC strategy and 
generalized epidemics such as those in most Sub-Saharan Africa.
    Recent data from Kenya, Zimbabwe and urban Haiti show 
declines in HIV prevalence. A new study has concluded that 
these reductions in prevalence do not simply represent the 
natural course of these nations' epidemics, but can only be 
explained by changes in sexual behavior.
    In Kenya, the Ministry of Health estimated that prevalence 
dropped by 30 percent over a 5-year period ending in 2003. The 
decline correlated with a broad reduction in sexual behavior, 
including increased male faithfulness, as measured by a 50 
percent reduction in young men with multiple sexual partners; 
primary abstinence, as measured by delayed sexual debut; and 
secondary abstinence, as measured by those that have been 
sexually active but refrained from activity over the past year, 
and increased use of condoms by young women who engage in risky 
activity.
    In an area in Zimbabwe, the journal Science reported a 23 
percent reduction in prevalence among young men, and a 
remarkable 49 percent decline among young women, also during 
the 5-year period ending in 2003. Again, the article correlates 
significant behavior change consistent with ABC with the 
decrease in prevalence.
    Because of the data, ABC is now recognized as the most 
effective strategy to prevent HIV/AIDS in generalized 
epidemics. The GAO report notes the consensus among U.S. 
Government field personnel that ABC is the right approach to 
prevention.
    To the extent any controversy remains around ABC, I believe 
that it stems from a misunderstanding. ABC is not a narrow one-
size-fits-all recipe, it encompasses a wide variety of 
approaches through a myriad of factors that lead to sexual 
transmission. For example, the Emergency Plan recognizes the 
critical need to address the inequalities among women and men 
that influence behavior change necessary to prevent HIV. 
PEPFAR-supported ABC programs address gender issues, to include 
violence against women, cross generational sex and 
transactional sex. Such approaches are not in conflict with 
ABC, they are integral to it.
    Some of the most striking data presented at our recent 
implementers meeting in Durban concerned behavior change by 
men, the B, or being faithful element of the ABC strategy. In a 
number of places men have begun toreduce their number of sexual 
partners through ABC interventions.
    The ABC programs also address the issue of prevention for 
HIV positive people, helping infected people to choose whether 
to abstain from activity, to be faithful to a single partner 
whose status is known, and use of condoms. ABC programs offers 
people information on how alcohol abuse can lead them into 
risky sexual behavior, and work with HIV positive injecting 
drug users so they can avoid sexual transmission of HIV/AIDS.
    And ABC programs link people to counseling and testing 
because we know people who know their HIV status are more 
likely to protect themselves and others from infection.
    Now of course we also support national strategies to 
prevent mother-to-child transmission and transmission through 
unsafe blood and medical injections, in addition to programs 
that teach ABC messages to injection drug users. The Emergency 
Plan supports programs that work with drug users to free them 
from their addiction through prevention and education, and 
through substitution therapy, an approach that has been 
scientifically proven to reduce HIV/AIDS infection while 
providing clinical treatment for addiction.
    I'd like to address the effect of the congressional 
prevention directive. The authorizing legislation recommends 
that 20 percent of funds in the focus country be allocated for 
prevention, and directs that at least 33 percent of prevention 
funding be allocated to abstinence-until-marriage programs. As 
has been noted, we count programs that focus on abstinence and 
faithfulness for this purpose, and this 33 percent requirement 
is applied to all countries collectively, and PEPFAR has met 
it.
    The legislation's emphasis on ABC activities has been an 
important factor on the fundamental and needed shift in U.S. 
Government prevention strategy from a primarily C approach 
prior to PEPFAR to a balanced ABC strategy. PEPFAR has followed 
Congress' mandate that it is possible and necessary to strongly 
emphasize A, B and C.
    The congressional directive, which itself reflects an 
evidence-based public health understanding of the importance of 
ABC, has helped to support PEPFAR's field personnel in 
appropriately broadening the range of prevention efforts. The 
directive has helped PEPFAR to align itself with the host 
nations, of which ABC is a key element.
    PEPFAR does offer each focus country team the opportunity 
to propose and provide justification for a different prevention 
funding allocation based on the circumstances in that country. 
To date, all such justifications have been approved without 
requiring other countries to make offsetting judgments to their 
proposed prevention allocations.
    It is also important to remember that the U.S. Government 
is not the only source of funding in-country, and that partners 
can seek funding from other sources to balance their mix of 
prevention interventions if they find that necessary. In fact, 
money does not always follow the evidence. As the Minister of 
Health in Namibia noted in a recent letter to the editor of the 
Lancet, PEPFAR support for AB is needed to ensure the balanced 
ABC approach that Namibia seeks, and this is because other 
international partners primarily support C interventions.
    Last, let me address the issue of how we are monitoring and 
evaluating our prevention efforts. We strongly believe that we 
need to focus not only on the inputs but on results, the number 
of HIV infections averted to PEPFAR interventions.
    Obviously we cannot measure directly the number of 
infections that would have occurred without U.S. Government 
support. One area for prevention for which we are using a model 
to estimate infections averted is prevention of mother-to-child 
transmission, or PMT CT.
    Through March 2006, we supported PMTCT services for more 
than 4.5 million pregnancies. It is noteworthy that the number 
of women served grew dramatically from 821,000 in the first 
half of 2005 to almost 1.3 million in the first half of 2006, a 
57 percent increase. This is clearly related to the 59 percent 
increase in PMTCT funding managed in the focus countries over 
the course of PEPFAR, from $44 million in 2004 to $71 million 
this year. And these numbers do not include HIV positive 
pregnant women who receive other PEPFAR supported services, 
including treatment, care, counseling and testing, and other 
prevention interventions.
    In over 342 pregnancies, the women were identified as HIV 
positive and given antiretroviral prophylaxis to prevent 
infections of their children. Using an internationally agreed 
model, we estimate that this intervention averted approximately 
65,100 infant infections through March of this year.
    For prevention as a whole, including sexual and medical 
transmission, we are working to develop the best possible 
models to allow us to estimate the numbers of infections that 
PEPFAR supported programs have averted.
    Mr. Chairman, there has been a sense of fatalism about HIV 
prevention in many quarters; it is long past time to discard 
that attitude. The world community must come alongside 
governments, civil society, faith-based organizations and 
others to support their leadership in the sustainability of the 
HIV prevention programs through effective prevention. The U.S. 
Government, for our part, considers it a privilege to do so.
    The initial years of the Emergency Plan have demonstrated 
that prevention can work in many of the world's most difficult 
places. Through PEPFAR, the American people have become leaders 
in the world effort to turn the tide against HIV/AIDS.
    Mr. Chairman, thank you very much, and I'd be happy to 
address your questions.
    [The prepared statement of Ambassador Dybul follows:]

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    Mr. Shays. Thank you very much. Dr. Hill.

                     STATEMENT OF KENT HILL

    Dr. Hill. Mr. Chairman, and members of the subcommittee, as 
Assistant Administrator of the Bureau for Global Health at 
USAID, it is my privilege to testify on the importance of 
prevention in the President's Emergency Plan for AIDS, and to 
testify with my friend, Ambassador Dybul.
    This discussion is particularly timely as only 3 weeks ago 
the 16th International AIDS Conference came to a close in 
Toronto, Canada. Against the backdrop of that conference, I 
returned to Washington with three overarching themes dominant 
in my thinking.
    First, the United States is recognized as a global leader 
in the fight against HIV/AIDS. The sheer magnitude of the 
resources the United States has committed to this single 
disease is unprecedented beyond that of any other nation in the 
world.
    Second, the fight against HIV/AIDS is far from over. Four 
million new infections every year means that we must markedly 
scale up and strengthen the prevention of new HIV infections 
globally.
    And third, although opinions can and do diverge regarding 
the relative importance of various prevention interventions, we 
must differentiate between legitimate debate and the much more 
common misinformation so often associated with discussion of 
the U.S. endorsement of ABC, the abstinence or delay of sexual 
debut, the be faithful or at least the reduction of partners, 
and the correct and consistent use of condoms.
    As Ambassador Dybul said, the ABC approach is an evidence-
based, flexible approach and common sense based strategy which 
plays a major role in stemming the tide of HIV/AIDS pandemic.
    It is too important to be bogged down in the politics of 
passion, too much is at stake, too many lives hang in the 
balance, too many children are vulnerable to become orphans if 
we fail in our prevention efforts. And it should be noted that 
one way to raise the quality of the discussion of ABC 
prevention intervention is to absolutely insist that it take 
place in the context of gender issues. After all, many of the 
problems associated with the spread of HIV are intimately 
connected with the absence of gender equity, the presence of 
gender-based violence and coercion typical of transactional and 
transgenerational sex. For all too many young girls, abstinence 
is not about being morally conservative, it is about having the 
right to abstain. The double standards of men who are 
unfaithful while their wives are is a gender equity issue. In 
short, AB interventions much be seen as fundamentally linked to 
gender and equality issues, a topic which can unite left and 
right, liberals and conservatives. We need to focus on the 
common ground.
    The ABC approach to HIV prevention is good public health, 
based on respect for local culture. As has been stated, is it 
an African solution developed in Africa, not in the United 
States, and it has universally adaptable themes. To amplify 
this point, in May 2006 the Southern Africa Development 
Community, an alliance of several countries in southern Africa, 
convened an expert think tank meeting to identify and mobilize 
key regional priorities of HIV prevention. The media report 
characterized multiple and concurrent sexual partnerships as 
essential drivers of the HIV/AIDS epidemic in the southern 
Africa region. They recommended in light of this fact that 
priority be given to the interventions that reduce the number 
of multiple and concurrent partnerships, address male behavior 
involvement, increase consistent and correct condom use, and 
continue programming around delayed sexual debut. Clearly these 
are African derived interventions that address ABC behaviors.
    In the field, we are taking steps to find out how well our 
programs are working. In addition to our normal evaluation of 
program effectiveness, USAID is leading U.S. Government 
agencies in an independent evaluation, one not done by USG 
folks, of some PEPFAR supported ABC programs. An expert meeting 
was convened to develop new evaluation tools to measure program 
implementation and strengths. This will be followed by a longer 
term program evaluation that will be multi-country in nature, 
and will provide important information on program strengths and 
outcomes. We're excited about this progress and look forward to 
the findings which will be used to improve program performance.
    One promising, yet overlooked aspect of the Emergency Plan, 
is its increased attention to issues of male behavior, which 
lie at the heart of women's sexual vulnerability and sexual 
coercion. I'd like to give you some examples of what I'm 
talking about here.
    In South Africa, the Emergency Plan works with the 
Institute For Health and Development Communication's Soul City, 
the most expansive HIV/AIDS communication intervention in the 
country, reaching about 80 percent of the population. Soul City 
emphasizes the role of men in parenting and caring. It 
challenges social norms around men's perceived right to sex, 
sexual violence, and intergenerational sex. There is 
statistical correlation between exposure to Soul City 
programming and improved norms and values amongst men.
    Also in South Africa, the Emergency Plan supports a very 
successful male involvement program known as Men As Partners. 
In addition to dealing HIV/AIDS prevention issues that include 
masculinity, stigma, domestic violence, men are encouraged to 
assume a larger share of responsibilities for family and 
community care by spending more time with their children, 
mentoring young boys in the community, and visiting terminally 
ill AIDS patients.
    Or take for example, Zambia. The United States is working 
with the Zambian Defense Force to train peer educators and 
commanding officers to raise awareness among men in the 
military about the threat posed by HIV/AIDS and to enlist their 
support in addressing it. Training workshops cover basic facts 
about HIV/AIDS and its impact, including transmission, 
prevention, stigma, sexuality, gender, positive living, 
counseling, testing and care.
    I'm going to skip Uganda. A lot has been said about that 
before, but there are a lot of good things that can be said 
here, and go on to Namibia.
    The Lifeline Childline program addresses the root causes of 
gender violence. It uses age-appropriate messages to teach 
boys--as well as girls--about HIV/AIDS sexual abuse, domestic 
violence, and the resources available to vulnerable children 
through specialized counseling and other services.
    And I'd like to conclude by underscoring the 2004 Lancet 
commentary on finding common ground. This was a piece signed by 
150 AIDS experts, some in this room, from around the world, 
noting that the ABC approach can play an important role in 
reducing the prevalence in a generalized epidemic, and that 
partner reduction is of central epidemiological importance in 
achieving large scale HIV incidents reduction, both in 
generalized and in more concentrated epidemics.
    Through partnership with host nations, effective programs 
for HIV prevention are possible even in the most difficult 
places. We will continue to support this common ground as we 
continue our massive response to HIV and AIDS.
    Congressional commitment to a comprehensive HIV prevention 
strategy is the correct approach, and one clearly supported by 
the evidence. Thank you.
    [The prepared statement of Dr. Hill follows:]

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    Mr. Shays. Thank you very much.
    Mr. Duncan, we'll have you start off.
    Mr. Duncan. Well, thank you very much, Mr. Chairman.
    Let me ask this. We have a GAO report that says that the 
PEPFAR prevention budget is $322 million, and that's 20 percent 
of the total PEPFAR budget, which would mean the total PEPFAR 
budget would be approximately $1.6 billion; is that close to 
being correct?
    Ambassador Dybul. Yes, sir, that is correct, in terms of 
the 15 focus countries that were mentioned by the chairman. The 
entire PEPFAR budget encompasses other bilateral programs, it 
encompasses international research on HIV/AIDS, and it also 
encompasses our contribution to the Global Fund for AIDS, 
tuberculosis and malaria, which is substantial. So it would be 
$1.6 of $3.2 billion, approximately.
    Mr. Duncan. According to CRS, it says we're giving about 
$350 million, roughly, to the Global Fund over the last couple 
of years, each year.
    Ambassador Dybul. Correct.
    Mr. Duncan. So the total PEPFAR budget is $3.2 billion.
    Is there any other country that is contributing figures 
like that to fight AIDS outside of their own country that you 
know of?
    Ambassador Dybul. Tragically, no. According to a recent 
analysis by the Kaiser Family Foundation, the American people 
are providing approximately half of all global partner 
resources for HIV/AIDS. No one is in the category of the United 
States. In fact, the United States provides as much as all 
other international what is called donors,a word I really don't 
like because we're talking about donors/recipients, we're 
talking about partners--but yes, we provide as much as everyone 
else combined.
    Mr. Duncan. You know, I think that's very important because 
I think some of these are really good things for us to do, but 
so often the American taxpayers just don't get nearly the 
credit that they deserve because we're doing far more in this 
area than any other country. No other country, even developed 
nations, are coming close. And this money for the most part is 
being spent in countries where the cost of medical care is far, 
far cheaper or far less than it is in this country; is that 
correct?
    Ambassador Dybul. Yes, sir. It would be true that the cost 
per person for nearly every intervention is lower in the 
countries in which we're working than it would be in the United 
States.
    Mr. Duncan. Let me ask you this, a later witness apparently 
will testify, or part of his statement says, now PEPFAR and 
USAID lead the world in AIDS prevention, promoting a balanced 
and targeted set of interventions that include abstinence, 
being faithful and condoms for those who cannot and will not 
follow A or B behaviors. This is in spite of formidable and 
continuing institutional resistance to change. As a senior 
USAID officer commented not long ago, ``USAID is in the condom 
and contraceptive business, that is our business.''
    Do either one of you, are you finding this formidable and 
continuing institutional resistance to change that this later 
witness refers to?
    Ambassador Dybul. Well, sir, let me begin, and then Dr. 
Hill, I'm sure, will want to comment on that.
    I think one of the important pieces of the GAO report that 
has not been commented on often is that in three or four places 
it states that there is now a consensus by American government 
personnel in the field that ABC is a balanced approach as what 
is needed. Now that doesn't mean there aren't people who are 
still attached to older philosophies. I actually come to HIV/
AIDS as a therapeutic scientist and researcher, and it's become 
very clear, if you look at prevention data--which I've done, I 
didn't enter this with any particular dog in the race, I just 
wanted to look at the data as a scientist--that the data for 
ABC are overwhelming. There is no example of a decline in HIV 
prevalence in a generalized epidemic such as Africa without all 
three components, without all three ABC components.
    But most of the initial prevention work that was done was 
not in generalized epidemics, it was in what's called 
concentrated epidemics, places where identified populations are 
at high risk, prostitutes, men having sex with men, truck 
drivers, and much of the initial work was done in those 
populations. And they're more of a BC message, which is shown 
to be highly effective. Unfortunately what's happened is some 
people tried to transfer data from a concentrated epidemic--
because that's the work they were familiar with--to a 
generalized epidemic, and we still have people holding on to 
the old data set, not moving to the new data set. But that is 
increasingly becoming less and less of an issue as the data are 
overwhelming. But we see this unfortunately in any 
circumstance. In treatment we still have people who want to use 
two instead of three drugs because they haven't caught up with 
the data. So we do have to continually educate and provide the 
data, and the data base is growing substantially.
    I think we've largely overcome some of those earlier 
prejudices as the data become available, but it's a constant 
effort and we're still working on it.
    Mr. Duncan. Before Dr. Hill comments, let me, before my 
time runs out--and maybe Dr. Hill will want to comment on 
this--that's a very good answer, Mr. Ambassador, that you've 
just given me, but also another later witness will mention the 
point about where women do not have the power to refuse 
unprotected sex and it says that's the problem, not the 
presence of abstinence or faithfulness per se. Now maybe one or 
both of you might want to comment about that, in addition to 
these other comments or answers.
    Ambassador Dybul. Again, if I could start and then Dr. Hill 
could answer both of those two pieces.
    You know, in the case of gender equality or violence 
against women, negotiating A, B or C is a very difficult 
endeavor. So as Dr. Hill mentioned, we need to deal with some 
of the entrenched gender issues, and we are, in fact, dealing 
with those. We're dealing with those in terms of transactional 
sex, transgenerational sex, we're teaching young men a lot of 
important lessons about respecting women. We're tying our 
programs to issues of gender violence, including the 
President's initiative on women's empowerment. All of those are 
important, but I think it is also important that the ABC 
message is relevant for gender inequality; if men learn ABC, if 
men practice ABC, gender issues become easier to deal with 
because the men themselves will allow for the negotiation of an 
A, B or C intervention. We've seen over and over again the data 
for young men radically changing their B behavior, becoming 
faithful, reducing their partners as a major reason for 
declines in prevalence, and that is very much affecting the 
gender issue.
    So I think as in most things related to HIV/AIDS, any time 
we begin with this or that, we're making a mistake, it's 
generally everything and all and more. And so we need all of 
these approaches to deal with gender. But ABC is very relevant 
for gender, particularly if you target the men, and we have a 
lot of programs to do that, particularly young men.
    Mr. Duncan. Plus some of that training for men on teaching 
respect for women and so forth would help curb this program in 
the future. You can't solve this problem immediately or all at 
once.
    Dr. Hill, I didn't mean to cut you off. I'd be interested 
in your comment.
    Dr. Hill. Congressman Duncan, let me begin with your first 
question as to whether in fact there is resistance among career 
people to a comprehensive ABC approach and if there is a 
favoritism toward the C.
    I think if you talk to career people about this, they will 
be the first to acknowledge that the international approach, 
including much the of the U.S. approach, in the initial years 
did tend to view condoms as a kind of silver bullet that might 
have a huge impact on this. But as the evidence begin to mount 
that condoms were not going to be enough, and as the evidence 
mounted as to how prevalence rates were going down in Uganda 
precisely by using a comprehensive approach, a lot of talk 
about what they would refer to as zero grazing or partner 
reduction or monogamy within marriage, etc., faithfulness 
within the sexual partnerships, when the evidence began to come 
in that it was this behavior change that was having a dramatic 
impact on the lowering of prevalence, career people, it didn't 
matter if they were Democrat or conservative, religious or non-
religious, they could see the facts, they could tell that these 
interventions had a lot more potential than they at first 
perhaps thought. And so I feel very strongly that the core team 
of professionals with whom I work with at USAID--and I think 
this is true of the other Federal agencies--have really had a 
remarkable shift toward understanding the importance of a 
comprehensive approach. I feel very good about that.
    Now, internationally, we have a long ways to go to have won 
that battle. And in fact, I really honestly believe that the 
battle is there. And Ambassador Dybul is absolutely right to 
point out that one of the reasons is so critical that the 
United States spend sufficient attention on AB is because 
you're not likely to find it anywhere else. It's not going to 
be there yet because people don't yet believe that it's going 
to be that effective.
    And so what I really think we've got to do is two things. 
We have simply got to focus the world's attention on the fact 
that this is an evidence-based approach, that all the data 
suggests that it can be very, very effective. What I find 
fascinating is that even in a place like Asia where we focused 
on condoms, AB behaviors changed as well. The percentages of 
young men that were having their first sexual experience with 
sex workers or prostitutes went down. The number of police that 
were visiting sex workers or prostitutes went down. Throughout 
many parts of Africa, the evidence suggested people could 
change their behavior, even to the point of changing to 
abstinence or to partner reduction if they were sexually 
experienced. So the evidence is very strong.
    The second thing that I think will help get this out of 
what I call the culture wars debate is to emphasize the 
connection to gender issues. This is a winner of an approach 
that will affect gender issues. You cannot affect gender 
inequality issues or equality issues without doing AB 
interventions, they're critically important to it.
    Your last point about--I'm trying to remember what your 
last point was--had to do with----
    Mr. Duncan. It was about the women who----
    Dr. Hill. Right. Whether it's realistic--and I think there 
have been two myths that have been perpetrated. One is that 
abstinence is not realistic with the young. They simply aren't 
capable of it. Their hormones are too strong. And the second of 
course is that be faithful programs don't work when the husband 
is not faithful. The latter point of course is absolutely 
obvious. That's why you have to focus on male behavior and not 
just female behavior. But the evidence is also overwhelming 
that young people are quite capable of moderating their 
behavior as well.
    So I think what's really needed is for more than ABC, it's 
gender programs, it's working with pregnant women, it's 
treatment programs so that people when they get tested and 
change their behaviors have some hope for the future. It's all 
connected, and we've got to never treat it in an isolated 
fashion.
    Mr. Duncan. Thank you, Mr. Chairman.
    Mr. Shays. Thank you. Mr. Waxman, you have the floor.
    Mr. Waxman. Thank you, Mr. Chairman.
    Ambassador Dybul, there are several countries where overall 
prevalence rates have come down significantly. They include 
Uganda, Kenya and Zimbabwe; is that correct?
    Ambassador Dybul. That is correct, those three; there are 
many others, actually.
    Mr. Waxman. Well, experts have identified multiple reasons 
for these declines. Some factors have nothing to do with 
behavior change. For example, when young people who have high 
infection rates leave the country for economic reasons, average 
prevalence goes down; and sadly, prevalence also goes down when 
death rates are high. But we do know that in these countries 
there have been some positive behavior changes. Can you give us 
some of the examples?
    Ambassador Dybul. Yes, I'd be glad to. And I think you 
raise a very important point about other factors. There's no 
question there are other factors, and this is a very 
complicated scientific approach. However, the recent report 
from Zimbabwe, for example, looked very specifically at whether 
or not death contributed to the decline in prevalence, and they 
looked very scientifically at that in Science Magazine. Only 6 
percent of the decline in prevalence was due to death or other 
factors, only 6 percent. And the report, I mentioned in my 
testimony where a group looked across the board at multiple 
countries, about 10 actually, they determined that the decline 
in prevalence was in fact substantial behavior change. While 
these other things contributed, it was substantial behavior 
change.
    A couple of the examples that we can give, whether it's 
Uganda, Kenya or Zimbabwe, which probably have the most up to 
date solid data in this respect--we're still looking at some of 
the other countries--as I mentioned, 50 percent decline in 
young men who had multiple partnerships. Increase in age of 
first sexual activity by a year or so, and in fact this overall 
survey determined that, as in Uganda, was probably one of the 
most substantial reasons why we saw a decline in prevalence 
because just that shift in a year remarkably shifts the 
epidemiology of the infection as less people become infected 
early who then infect less people. That's a very significant 
impact.
    Importantly, secondary abstinence, building on what Dr. 
Hill just said, Kenya actually looked in their demographic 
health survey at people who had previously been sexually active 
versus those who had been sexually active in the last year; 
secondary abstinence, people who have been active sexually and 
no longer were, and saw remarkable progress there, 50 percent.
    We also saw, both in the Zimbabwe data and in the Kenya 
data, as in the Uganda data, some increase in condom use 
particularly among young women, now a doubling of the use of 
condom use among young women. Unfortunately we didn't quite see 
a commensurate change among the young men.
    So it is a complex picture, but the data are repeated over 
and over again supporting A, B and C.
    Mr. Waxman. My understanding of the epidemiology is that we 
can link these behavior changes to lower prevalence rates, but 
what we generally can't do is say this program led to that 
behavior change, resulting in lower prevalence. Can you explain 
that?
    Ambassador Dybul. Yes, and this gets to the complicated 
nature of behavioral science. Aristotle once said you can only 
be as precise as your subject matter allows, and unfortunately 
that is the case with behavioral science. Unlike treatment, 
where you can follow someone's CD-4 cell count or follow their 
viral load, behavior signs is a much different thing. So what 
we do is look at prevalence rates, as we've talked about, and 
we look at behavior change that has occurred over that same 
time period. You can then link and say this program led to this 
effect. You can look to see where programs were introduced and 
whether or not they were introduced largely, and whether or 
not--you can basically guesstimate that those programs in fact 
led to the change in behavior that was correlated with the 
decline in prevalence. It's a much more complicated matter than 
most sciences.
    Mr. Waxman. I think that's an important point to highlight 
because there's a tendency to get bogged down in arguments over 
exactly which kind of program got results at a national level, 
but we can't make that kind of claim. We can only know that in 
certain countries that did implement comprehensive programs, 
significant behavior changes have led to decreased prevalence. 
While it's important to clarify the limits of our current 
knowledge, we do need to get more precise information on how 
specific interventions impact behavioral change. What are we 
doing to study this?
    Ambassador Dybul. And that's an important point because 
that is something you can do in a scientific way is look at 
programs and see what impact they've had on behavior change. We 
actually do this in a variety of ways. Many partners do it 
themselves, and in fact we just had a meeting in Durban, South 
Africa where 700 scientific abstracts were presented, including 
quite a few on this topic, where, for example, in Nigeria they 
introduced what's called the zip-up campaign, and during the 
time that the zip-up campaign--which was an abstinence 
campaign--was in play, they saw a dramatic increase in 
abstinence activities. We have looked at programs on college 
campuses where we've introduced such ABC programs and looked at 
the change among those participants.
    We have done a number of what we call targeted evaluations 
to look at this approach. These take a long time. They 
generally take a couple of years. Dr. Hill talked about a 
couple that USAID is doing. We're also shifting the way we're 
doing things, moving from a targeted evaluation approach to 
public health evaluation approach so that we can do more and 
more of these efforts, and they are ongoing----
    Mr. Waxman. Ambassador Dybul, I have a lot of other 
questions, but I appreciate your answer to that. And I think 
these evaluations are extremely important. I also think that 
country teams should have the flexibility to refine their 
prevention programs based on the evidence we glean from these 
studies in the coming years.
    Your office has turned the one-third requirement into two 
parts; countries must spend at least 50 percent of prevention 
funds on sexual transmission; then they must spend 66 percent 
of those funds on AB programs. I understand that a number of 
countries were able to get exemption from one or both of these 
requirements; isn't that correct?
    Ambassador Dybul. That's correct.
    Mr. Waxman. Now for the countries that didn't get 
exemptions, the formula means that if they spend more than 50 
percent on sexual transmission, they must spend more than 33 
percent on AB programs; is that right?
    Ambassador Dybul. That's correct. And that makes some 
sense. I'd be happy to explain that.
    Mr. Waxman. In response to the GAO report, the 
administration said that--you asked those countries that didn't 
apply for exemptions if they wanted to, and you wrote that the 
answer was a resounding no. I'd like to read into the record 
what U.S. guidance is to these countries.
    Both in 2006 and 2007 guidance state, ``please note that in 
a generalized epidemic a very strong justification is required 
to not meet the 66 percent AB requirement.'' The 2006 guidance 
also said, ``we expect that all focus countries, and in 
particular those with budgets that exceed $75 million, will 
meet these requirements.''
    In addition, both years guidance state, ``in any case, no 
country should decrease from 1 year to the next the percent of 
sexual transmission activities that are AB. There will be no 
exceptions to this requirement.''
    I think that it's difficult to know what country would 
really have deferred, absent this strong language from their 
biggest donor.
    Ambassador Dybul, I'd like to ask you a few questions about 
male circumcisions. I understand that four of these studies 
have indicated male circumcision decreases the risk of a man 
contracting HIV, and one randomized control study showed that 
male circumcision lowered the risk by about 75 percent. Lower 
rates of HIV among men will mean fewer risks for women in the 
population. Can you tell us what the United States is doing to 
assess the appropriate role of male circumcision in HIV 
prevention?
    Ambassador Dybul. I'd be happy to. I'd first like to get 
back to some of the difficult issues you raised with behavioral 
data.
    Mr. Waxman. Excuse me, Ambassador Dybul. My problem is that 
in another second or two the light is going to switch, so I 
really do have to move on.
    Ambassador Dybul. I would just say in a sentence that most 
of those studies----
    Mr. Waxman. The chairman said I can have as much time as I 
want, so please feel free to go back. And we'll stay here all 
day.
    Mr. Shays. No. The bottom line is that we don't have a lot 
of members, but if Mr. Waxman wants you to answer another 
question, he has the privilege to ask you to go to the next 
one.
    Ambassador Dybul. Most of those studies just showed an 
association between people who were circumcised and the 
protection. There are now a couple of studies that were just 
presented in Toronto that showed that in fact isn't holding up. 
That one randomized control target you mentioned looked at the 
actual intervention; programmatically if we proactively did 
circumcision, would there be a benefit. One trial has shown a 
benefit, a 60 to 70 percent reduction to men, it said nothing 
about the women. It also showed an increase in sexual activity 
by the young men, and there's actually a mathematical model 
that shows if men think they're fully protected and have more 
activity, you can actually offset the benefit of the 
circumcision.
    Mr. Waxman. Let's take that first part. If men don't get 
HIV because they're circumcised, it does help the women because 
if they do have sexual activity----
    Ambassador Dybul. The problem is that they do, they just 
get a lower rate. It's a 60 to 70 percent reduction. So that's 
why you can actually mathematically show that if men increase 
their activity by a certain percent it will offset the benefit 
of the circumcision. We don't know that. That's a guesstimate.
    There are two other randomized controlled trials, large 
trials that are underway right now, they're ongoing. The Data 
Safety Monitoring Board has twice not stopped the studies; in 
other words, allowed them to continue. We don't know what that 
means. We are expecting data in the next 6 to 12 months, 
depending on whether they get to their end points.
    These studies look a little more carefully at some of the 
other issues involved. In anticipation of those studies, 
because we don't know the results and it would not be 
responsible, no one in the world right now is advocating--no 
major international organizations are advocating active 
programmatic use of circumcision, but what we have done is 
given countries flexibility--and several have through our 
resources--to do preliminary work, to do preparatory work. 
Unfortunately, as you know, circumcision does have cultural 
connotations to many people, and so we're doing some of the 
cultural sensitivity work, just like we have to do for vaccines 
and other work. Should circumcision be proven to be effective 
and have normative guidance, one implementing agency, not a 
scientific agency, that's NIH and other people's business, 
should there be normative guidance on the use of circumcision, 
it is something we would fund, but we will do it carefully 
because you need to provide the ongoing ABC behavior change 
with the circumcision or you can actually offset the benefit.
    Mr. Waxman. I appreciate that answer. I certainly hope--and 
we're going to have to look at the evidence--that this can help 
in reducing HIV transmission. I also hope that if and when the 
time is right program staff will have the funding and 
flexibility to implement it, and I see you shaking your head.
    Mr. Hill, I'd like to ask you about the role that the one-
third earmark has played in the policy. There are some who say 
before the President's program started there was too much 
emphasis on condoms. And I gather that was your view as you 
expressed it earlier; is that correct?
    Dr. Hill. I think that's what my career folks tell me; they 
tell me that there was a tendency to focus on condoms, yes.
    Mr. Waxman. And do you think things have changed since 
PEPFAR started?
    Dr. Hill. Yes. Both because of the evidence, because we 
were forced to look at the evidence closely. So no, I think 
it's quite a different situation now. The best empirical 
studies on this are given by career people, not by political 
appointees.
    Mr. Waxman. If the legislative earmark were to be removed 
or modified, would USAID and its partner agencies still work to 
ensure that abstinence and be faithful programs play an 
appropriate role in country's HIV prevention programs?
    Dr. Hill. I'd like to think we would. As an implementer, 
you know that all implementers like flexibility, they like the 
options of making their own decisions on how to do things. But 
I do think it's appropriate and right for Congress to insist 
that we have a comprehensive strategy, but I'd like to believe 
we would do the right thing anyway.
    Mr. Waxman. Well, Dr. Dybul's office has the authority to 
approve or reject a country team's plans each year, and I trust 
that if the arbitrary quota for abstinence programs is removed, 
you both, along with our health experts in the field, would 
maintain AB programming where it is supported by evidence and 
by local needs.
    Ambassador Dybul, you noted in your testimony the U.S. 
continues to support condoms and condoms programs. While many 
believe that we are not doing enough to promote and fund condom 
use, you clearly agree that condoms are a crucial component of 
an effective prevention program.
    I have a question about appropriations language that has 
been referred to as the condom nondisparagement provision. It 
says, ``information provided about the use of condoms as part 
of projects or activities that are funded from amounts 
appropriated by this act shall be medically accurate and shall 
include the public health benefits and failure rates of such 
use.''
    Well when used consistently and correctly, condoms reduce 
HIV transmission by 85 percent to 95 percent. But there have 
been disturbing reports of programs that teach that condoms 
have holes or that they don't block HIV.
    What is the administration doing to ensure that U.S.-funded 
programs do not spread false information about condoms?
    Ambassador Dybul. Thank you for that question because it is 
an important one. Because we do have a full ABC approach as is 
evidenced by our funding distribution and by our guidance. We 
would take that provision of the law as seriously as any other 
provision. And so we make clear to everyone, and have done so 
on multiple occasions, that should anyone be aware of such 
activity occurring, such medical misinformation occurring, in a 
PEPFAR-funded program, we need to know about that, and we need 
to intervene either at the level of the cognizant technical 
officer and, if that is not successful, higher than that.
    Dr. Hill. There is actually in the USAID contract, for 
example, a very specific provision which requires any recipient 
of funds, even if all they are doing is AB programming, if they 
mention C, they have to mention it in a medically accurate way. 
If a report reaches us that they are not, that is a breach of 
what they signed.
    Mr. Waxman. I appreciate that answer.
    Thank you, Mr. Chairman.
    Mr. Shays. In answer to almost every question, there was 
the word ``evidence.'' And I am not quite sure how to take the 
word ``evidence.'' I am more inclined to want to say there are 
indications that. What scientific evidence is available that 
says that one-third should be for abstinence as opposed to two-
thirds or as opposed to one-sixth? Why one-third?
    Ambassador Dybul. Well, there is certainly no randomized 
controlled clinical trial that gives a percent of a program 
that should be dedicated to one or the other. What we do have 
are data that suggests very clearly that you need all three 
components, A, B and C, and 33 percent gives us a very balanced 
program.
    So you can't find a randomized controlled trial to give you 
that number, but you can find an interpretation or application 
of available data for a balanced approach that would get you to 
33 percent for AB.
    Mr. Shays. Dr. Hill, how would you answer the question?
    Dr. Hill. Well, I think the experience of PEPFAR in 
practice illustrates that, in fact, it is not viewed as rigid. 
There has been enough flexibility, Congress has allowed enough 
flexibility, that when it was appropriate to not spend that 
amount, exceptions have been made. In some cases it would be 
appropriate to have a higher percentage.
    So, in fact, the way the program has been implemented shows 
a fair amount of flexibility.
    Mr. Shays. When would it make sense to have it higher than 
one-third?
    Dr. Hill. If it was a generalized epidemic, it is very 
possible that the messages to the general public that have to 
do with behavior and the behavior of young people and the 
behavior of sexually active people could have the biggest 
impact on lowering the prevalence rate. If it is not primarily 
being spread by truck drivers or by sex workers or prostitutes 
or in the high-risk groups, that it is a very good possibility 
the behavior change messages in AB are the things that will 
likely bring the prevalence rates down the fastest.
    Ambassador Dybul. In addition to that, Mr. Chairman, if I 
could add, again, we are not the only player. While we are as 
much as everyone else in the world combined, there are others. 
And so we ask our country teams to look at the circumstance in 
their country, getting to the comment by the Minister of Health 
in Namibia that he needs us, the United States, to provide 
substantial support for AB because no one else is doing it.
    Mr. Shays. Briefly describe three or four abstinence 
programs to me.
    Ambassador Dybul. I can describe some of the ones I have 
seen. I can give you a couple from different age groups, and, 
again, we have very few abstinence-only programs except for 
young kids. What we have are AB programs and ABC programs once 
you got above 15. So an example of an A only program would be a 
10-year-old school program where for 10-year-olds in schools, 
the teachers have sessions on a daily basis. And this is a 
program in Uganda where the kids in the morning learn about the 
importance of HIV-AIDS in their community and how they as a 10-
year-old can avoid it through abstinence.
    As you get older, the message changes to AB messages. So we 
have programs in older kids, but still under 14, where they 
talk about the importance of HIV-AIDS in the community, but 
also abstinence and fidelity overall. And this is in the 
school.
    Mr. Shays. So abstinence and fidelity in what terms?
    Ambassador Dybul. People use different terms, and, again, 
it is culturally sensitive. In many countries being faithful 
means go to church. So they use different terms such as zero 
grazing. In some countries the term abstinence doesn't 
resonate----
    Mr. Shays. I can see you explaining to someone that maybe 
they don't want to smoke because they will get cancer. That 
would have a huge impact.
    Ambassador Dybul. Absolutely. And that is----
    Mr. Shays. But it is more than just explaining that 
abstinence will protect you from getting HIV-AIDS. It is into 
more than just that, correct?
    Ambassador Dybul. If I understand the question correctly, 
it begins with the danger, the risk to you for HIV-AIDS.
    Mr. Shays. Let me say it this way: I think being honest 
with people is essentially important. Being able to tell 
someone that if they don't protect themselves, they will get--
and are involved in sexual activities, the risk is very high 
they will get HIV-AIDS.
    That seems like an honest thing to tell people. It seems 
like an honest thing to tell people that a lot of people are 
dying because of it. Those--if that is an abstinence program, 
it seems pretty logical.
    If you get into issues about, you know, about lifestyles, 
and how you might go to hell because you are not abstaining, 
and you are choosing the wrong direction, then I am just 
wondering about that. And is that part of the program?
    Ambassador Dybul. Our program is based in public health and 
in public health evidence, and different people come to that 
from different perspectives. The majority of, vast majority of, 
our programs--in fact, all the ones I have ever seen--begin 
with what you began with, which is that HIV-AIDS is a risk to 
you, and you need to protect yourselves so that you can live a 
healthy, productive life, and that is where most of them begin, 
nearly all of them begin.
    Mr. Shays. Do you have the scientific evidence to know 
which kind of abstinence program works better? Because I keep 
hearing the word ``evidence.'' I will tell you this: If you 
told me I would get AIDS, that gives me religion real quick.
    Ambassador Dybul. Well, it might, but unfortunately that is 
not always the case. Some of the most disturbing data I have 
seen are that children who are orphaned from AIDS, they watched 
both of their parents die from AIDS--they know they died from 
AIDS--still don't necessarily practice safe sex, still don't 
abstain, be faithful, or correct and consistent condom use. So 
even that immediate experience did not alter their behavior.
    On the other hand, I think there is general agreement that 
the data are not particularly good on this, but the fear of 
death has driven behavior change, whether it be in this country 
or in Africa, and perhaps one of the reasons we are starting to 
see an uptick in infection rates in this country and in Europe 
and in some parts of Africa might be fatigue with that message, 
that you hear it so many times, you don't respond to it. And 
there are some data on that as well.
    So the problem with behavior change is it is a long-term 
thing. If you keep telling the people the same thing for 5 
years, eventually it is going to go over their heads. And that 
is why behavior change is so difficult, why behavior medicine, 
why behavior science is so difficult, because it is finding 
messages that link to and lead to changes in behavior.
    And that is fundamentally what we do, culturally 
appropriate messages that resonate with people, which is why 
Nigerians talked about zip up and Ugandans talk about zero 
grazing. People look at what will be the best message. 
Sometimes that message is within your cultural context, within 
your religious context, in addition to the HIV-AIDS practices 
and the effect of HIV-AIDS within your culture, there are other 
reasons that you should practice safe sex.
    Sometimes it is because of the tribal system. One of our 
most effective is Massai warriors. Massai warriors become 
warriors when 13 or 14, I can't remember which. They are 
collected together as young men and are taught to go out and 
abuse women. Well, the program we intervened with was to teach 
them that it is actually manly to actually becoming a warrior 
to refrain and to respect women; that is, in fact, a manly 
action within that tribal tradition.
    So you have to find the right messages which will lead to 
behavior change. The Minister of Health----
    Mr. Shays. Let me comment on that last point.
    I have no problem with the logic of what you just said. I 
have a problem with saying that one-third goes toward this 
program. And, you know, what I am hearing, being very candid 
with each other, basically what I believe is that when we 
appropriated the dollars, frankly, it was--one way to get it 
done was to win over some who don't want condoms as--their 
dollars being spent on condoms so that they then say, at least 
I can justify that we are spreading the word of God to folks 
through abstinence and so on and feel comfortable. And what I 
then feel is that both of you have to step up to the plate and 
justify why we have done that.
    And so when I hear the word ``evidence,'' I have a hard 
time knowing the definition of evidence, but the program you 
just described, teaching a different behavior, I think there is 
logic to that. But there is no logic to me that says, that one-
third should go that way.
    Dr. Hill, as well, would you be able to just tell me some 
more examples of abstinence programs?
    Dr. Hill. Yes. The point I alluded to in my oral comments 
about Soul City in South Africa is probably one of the best I 
have heard about recently. They produced a whole series of 
films that were shown on prime-time television which all 
address different values, different responsible behavior, etc. 
It wasn't heavy hitting, always talking about HIV, but it set 
the context for how men should treat women, etc.
    And the initial evidence of this suggests that people are 
reconsidering behavior that, in fact, is problematic, that 
leads to the spread of HIV-AIDS. That's a good example of a 
very sophisticated behavior change program using medium.
    But if I might, I would like to just address this question 
of what reasons we give----
    Mr. Shays. I will give you a chance. I want to know more 
programs. So if either one of you want to tell me others.
    Dr. Hill. Other examples? A lot of what we do in countries 
is that we will fund youth clubs, so after-school activities 
where kids get together anyway to do sports or just get 
together to get help with respect to certain things, we find 
ways; we have implementers that will introduce topics that will 
bring up sexual conduct, etc. They can ask questions. We try to 
be age appropriate, etc. I met with some of these groups, had 
discussions with these kids, and there is every reason to 
believe that kind of discussion can be useful. And there is a 
lot of countries in which we fund those kind of youth clubs.
    Ambassador Dybul. A specific example of that would be in 
Kenya. I just visited a program where college kids became 
concerned about the pressures, the peer pressures. College kids 
themselves were concerned about the pressures that they saw 
themselves and their classmates under to engage in sexual 
activity. They conducted a survey which showed that only 20 
percent of the entering freshman had engaged in sexual activity 
in college, but 80 percent thought that their friends had. So 
you can see kind of the peer pressure and the disconnect 
between what people are actually doing and what they thought 
was going on.
    As a result of that, they put together a program that we 
are supporting to teach people that it is OK, in fact it is a 
good thing, both for public health and your own self-worth and 
respecting yourself, to remain abstinent, or, if you had been 
sexually active, to become abstinent. And these are the 
students themselves that put this program together.
    Dr. Hill. And these programs are called life skills 
programs in which they will set up drama, set up scenarios in 
which a young person might encounter, for example, an older 
man, some other generation offering a girl tuition or books or 
something in exchange for sexual services. This explains or 
this shows them, demonstrates for them, how they could say no, 
why they should say no.
    It addresses other questions where they are being coerced: 
How do you say no? How do you make sure that what you want is 
respected? You have to model that, and we often do that through 
drama.
    Ambassador Dybul. Another example of these types of 
programs which I think are important ones and get missed are 
ones that target men specifically. There are actually programs 
in Namibia that say sometimes stigma is a good thing to 
stigmatize older men who prey on younger women.
    Mr. Shays. We call them, what, sugar daddies.
    Ambassador Dybul. Exactly. So to stigmatize them, basically 
drive men out of the community who engage in and who 
participate in such activity, that is an ABC program.
    In a similar way the program Dr. Hill mentioned in South 
Africa, a wonderful young man started on his own when he was 14 
or 15, his father was an alcoholic, and he drew on the program 
because he saw the same thing, that his friends were abusing 
women. He started the program to go around from his own 
personal experience to explain why young men shouldn't behave 
that way toward women, why young men should respect women, why 
they are equal to each other, why you would have a healthier 
life as you move forward, and it has grown into now he is a 
national representative for a national program to target young 
men to teach them to respect women in an ABC way and to give 
ABC messages. So----
    Mr. Shays. Finish your sentence.
    What did you want to say, Dr. Hill, when I wanted to----
    Dr. Hill. I think you were onto something when you were 
probing the question of about sort of what are acceptable 
reasons to sort of pursue a behavior change. And there is this 
fear out there, I have heard it a lot internationally, I have 
heard it sometimes in this country, if it can be demonstrated 
that somebody used a moral argument for behavior change, that 
somehow we may be dangerously close to crossing some line that 
USG dollars should not be spent for. And I just want to suggest 
that I think as important the health reasons are, it would be 
counterproductive to misunderstand that human beings are far 
more than just material creatures. They don't just respond to 
motivations that have to do with their appetites. They often 
respond to motivations that have to do with doing the right 
thing, whether it is treating another person with respect. They 
get nothing out of it, they certainly don't get sex out of it, 
and yet people, young people, repeatedly demonstrate that they 
can respond to stimuli which says, you know, be a man, do 
something that shows that you are more than just an animal that 
is going to follow your sexual urges.
    One of the reasons that we like to work with faith-based 
groups is that they often approach people at that deeper level. 
And you can sometimes get young people to respond to moral 
pushing and prodding as easily or more easily and with more 
passion than just the health issues.
    So I think the tent has to be big enough to include people 
making all sorts of arguments. We tell the faith-based folks, 
use health arguments as well. And I tell the folks who just 
want to use faith arguments, be sensitive to your culture. And 
if these folks are from a Muslim culture or an orthodox culture 
or whatever the culture is, if there is something there which 
stresses monogamy or faithfulness or not lying, for goodness 
sakes use those arguments as well. We he have to stop the 
spread of HIV.
    Mr. Shays. I have absolutely no problem with there being an 
abstinence problem. I have a problem with stating that it needs 
to be one-third. That is my problem, and because some places 
maybe it should be two-thirds. I don't know.
    I doubt it. But I would think--and part of it, admittedly 
it is not based on a wide experience, but when I was in 
Tanzania and Uganda to hear people describe using condoms more 
than once because then they weren't available is pretty gross. 
To hear people describe having sex without condoms because they 
couldn't get it was pretty gross. To see people waiting in 
clinics to learn if they had HIV-AIDS--and I will tell you, it 
was--there were hundreds in every place we went, and we got to 
interview them. And we got to ask them--you know, here I am 
thinking they are waiting to learn if they are going to die. 
They are willing to answer questions about whatever I wanted to 
ask them.
    And what I was struck with was it would be an absolute 
outrage if someone could have had a condom and didn't, but 
somehow they weren't available because we were diverting money 
in a different direction.
    If you had a choice of teaching someone abstinence, and 
they weren't going to abstain, is it better that we did that, 
or is it better that we make sure that they have a condom?
    Dr. Hill. It is why you made a great case for a 
comprehensive approach. You can't do any of these interventions 
alone. There is a place for A. There is a place for B. There is 
a place for C.
    Mr. Shays. Let's agree with that, provided that the other 
two get what they need before abstinence gets what it needs.
    Dr. Hill. If you look at the statistics on condoms over the 
last 8 or 10 years, during the PEPFAR years we provided more 
condoms than in the previous years. So it is not that condoms 
are actually going down in terms of the number that we are 
providing. That is a robust and major part of our prevention. 
So we are not arguing that it should go down. It should be a 
big part of what we do.
    It also should be the case, and, as you know, it is not 
abstinence that is one-third, it is allowed to be interpreted 
as AB. And that is a very important part of the message, just 
as C is.
    Ambassador Dybul. If I could build on what Dr. Hill said, 
we, in fact, have had substantial increase in support for 
condoms under the emergency plan, 130 percent increase, and 110 
percent increase for AB. So we have had substantial increases 
across the board for A, B and C.
    Unfortunately it is not enough. We cannot, with the 
resources of the American people, cover everything, which is 
why we need the rest of the world to be doing a lot more they 
are doing.
    Mr. Shays. That we agree, but what I think I heard you say 
is that some people are not getting condoms because we simply 
can't provide them.
    Ambassador Dybul. And some people aren't getting AB 
messages yet because we can't them get to them. And some people 
are not getting PMTCT because we don't have----
    Mr. Shays. So what comes first?
    Ambassador Dybul. What comes first is what makes you avoid 
infection, which is A and B and, if you can't do that, C.
    Mr. Shays. What happens if you are trying to convince 
someone to abstain, but, guess what, they are going to have 
sex? Because as much as you both may not want them to for their 
own good, they are still going to do it.
    Ambassador Dybul. And that is precisely why when you are 
above the age of 14 the message is an ABC message. It is not 
one or the other. It is the public health information to allow 
people to have a choice. It is giving them the information that 
abstinence or fidelity to an HIV-negative partner is a 100 
percent way to avoid HIV infection, and there may be tribal and 
other messages that come into play with that. But if that isn't 
possible, if someone doesn't choose to do that, they have the 
information available through some vehicle that condoms will 
protect them. But we can't cover everything because we don't 
have the money.
    Mr. Shays. Let me ask you, if countries were allowed to 
decide for themselves whether to put one-third toward 
abstinence, would countries still decide to do it, or would 
they choose not to?
    Ambassador Dybul. I have little doubt that they would.
    Mr. Shays. Would what?
    Ambassador Dybul. Would support full ABC and put 
considerable resources toward AB, or more.
    Mr. Shays. Why require it?
    Ambassador Dybul. Because it is coming from the U.S. 
Government and not from those countries. If you look at the 
national strategies----
    Mr. Shays. That is the problem I have. If your answer to us 
is that they prove their worth to these countries, why do we 
just have--why do--in the only area why do we set aside one-
third for abstinence?
    Ambassador Dybul. It is actually not the only area. There 
are a number of congressional directives for other resource 
requirements of the emergency plan besides the 33 percent. 
There is treatment, there is orphans and vulnerable children, 
there are other directives. The national strategies of 
virtually every country in Africa where they have them lists 
ABC as their approach, not C. ABC.
    The Minister of Health of Namibia was very clear in his 
response in the Lancet report saying, I need the American 
people to be doing heavy AB because no one else is doing it. We 
get C from other folks. We don't get AB from anyone else. We 
need a direction that allows us to provide the full balanced 
message, not a single message.
    Mr. Shays. You kind of turned my question on end. I wasn't 
saying you would limit it. I would say if they want to spend 
two-thirds they could spend two-thirds. So I don't really think 
you were answering the question. The question was, why require 
it? And your answer, I guess, in the end is not based on 
science; based on the fact that Congress has required it, that 
is why we have it.
    You have done a very good job--I am interrupting you but 
you have done a very job of putting the best case forward I 
think you can do. But it still doesn't answer the question why 
it is one-third.
    Ambassador Dybul. I think you are right. Maybe it should be 
more than a third. I don't know, but the law is at least a 
third if not----
    Mr. Shays. I never said it should be nothing. I am saying 
if a country wants to spend more, that it could spend more. We 
are going to hear from other people in the second panel, but in 
my brief visit to Uganda and Tanzania, it was--I was struck by 
this fact. I was struck by the fact that when I spoke to 
college kids, they were telling me if they don't have condoms, 
they are still going to have sex, and so are their friends. 
That is what they said.
    And what they said is kids back in villages are still going 
to have sex no matter what you think about--however, you know, 
effective your abstinence programs are, they are still going to 
have sex. So you can decide to let them have sex without 
condoms, or you can let them decide to have sex with condoms. 
They are still going to have sex.
    Ambassador Dybul. Mr. Chairman, I think it gets back to 
your point on evidence. The evidence is that people are 
changing their behavior. The evidence is that we are seeing a 
reduction in partnerships and sexual activity.
    Mr. Shays. But the evidence is not clear if they are 
changing their behavior because we have an abstinence program 
that tells them the truth, by the way, you may get AIDS, or we 
have an abstinence program because it is better for your soul 
and you will grow up to be a better person. We don't have 
evidence as to what, why and which programs work.
    Ambassador Dybul. I think that is true, and I have stated 
that we don't know that yet. We do have some data on some 
programs; for example, the Zip Up Program in Nigeria. We do 
have data from some other programs, Soul City and a few others, 
and we are still working on those.
    The fact of the matter is that we need to have a broad-
scale ABC message to everyone in every place that condoms 
should be available to all those who need them. But the issue 
of priority of just providing condoms without AB we know is 
wrong, too.
    Unfortunately, and again this gets somewhat to the 
President's request, were the President's request met for the 
focused countries, we could increase AB and C. Would the rest 
of the world step up to its responsibility to match the United 
States, we could do enough AB and C.
    I don't think it has to do with the lack of availability of 
condoms to college kids any more than it has to do with lack of 
AB messages. It is a problem of resources and the rest coming 
from the rest of the world and the President's full budget 
being supported. But we have increased AB and C. We would like 
to increase it more, and we will increase all three of those 
more with additional resources.
    Mr. Shays. Is there any other comments you want to make 
before we get to the next panel? Is there anything we need to 
put on the record?
    Dr. Hill. I think I would just add that one way or another, 
whether it is by congressional directive of some sort which 
instructs us to make sure that we do a comprehensive approach--
because the basic message of ABC is critically important, it is 
going to vary little from country to country--one way or 
another, whether that prodding comes from you or comes from the 
Office of Global AIDS Coordinator or from central authorities 
in Washington, it is like any other guidance. It is given 
because you want to ensure that you get a balanced program that 
does as much as possible. Having some flexibility is fine, but 
we have to make sure that we push hard on this because, in 
fact, in the past it wasn't a balanced program, and this was an 
effort to try to make it more balanced.
    Mr. Shays. You wanted to say something?
    Ambassador Dybul. I would say I think this has been a very 
important hearing. I would just want to state that the American 
people through PEPFAR are supporting the broadest comprehensive 
HIV-AIDS prevention strategy in the world beyond question.
    I think we may do all of ourselves a disservice by 
concentrating too much on various percents when we know ABC is 
the proper message, and stick to supporting things and 
expanding programs and having that comprehensive base shifting 
as we go, should male circumcision, microbicides or other 
things become more available, but sticking to the basic sense 
that ABC is the foundation. Gender is something we need to deal 
with, alcohol, all of the things we are supporting, and try to 
focus more on what we can do going forward rather than focusing 
too much on a percent that isn't radically affecting things in 
the field in a negative way at all and, in fact, had some very 
positive----
    Mr. Shays. Let me put on the record my own view that you 
both are very dedicated people. You are taking a law that has 
been passed by Congress, and you are seeking to implement it. I 
know this is a morning, noon and night effort on your part and 
the people that work with you.
    I happen to be a very proud American of what we have done, 
and I know the President is criticized for a lot of things, 
some of which I have been, you know, out there criticizing him 
for. But I am very proud of our country's focus on this issue. 
As a former Peace Corps volunteer, I know that we are doing so 
much more than any other country, and so while we are asking 
you these questions, and we might have some disagreements, we 
don't have any disagreements over the importance of this issue 
and the dedication of your people, and we do appreciate your 
being here.
    I do want to recognize Barbara Lee. We are going to get on 
to our next panel, but I would just note that she has unanimous 
consent to participate in these hearings, and she is a real 
leader on this issue. Maybe you would like to just address 
these two gentlemen before they get on their way, and if you 
would like----
    Ms. Lee. Let me just first thank you. Forgive me for being 
late. I will definitely, though, review testimony, and 
appreciate everything that you are doing. And, Mr. Chairman, I 
just thank you for giving me the opportunity to sit in on this 
very important hearing.
    As you know, I helped write the PEPFAR legislation, and we 
want it to work. And I think today's hearing will let us know 
if it is working, if it is not working, what the abstinence-
only policies mean in the field, and what to do about them if 
they are not working.
    And I thank you very much, Mr. Chairman.
    [The prepared statement of Hon. Barbara Lee follows:]

    [GRAPHIC] [TIFF OMITTED] T5621.025
    
    [GRAPHIC] [TIFF OMITTED] T5621.026
    
    Mr. Shays. Thank you.
    Gentlemen, thank you both so very much. Appreciate your 
being here.
    Mr. Shays. We will ask the next panel to come in just 1 
minute.
    Our next panel is Dr. David Gootnick, Director, 
International Affairs and Trade, U.S. Government Accountability 
Office; Dr. Helene Gayle, president, chief executive officer, 
CARE USA; and Dr. Lucy Nkya, member of Tanzania Parliament, 
medical chairperson, Medical Board of St. Mary's Hospital, 
director, Faraja Trust Fund, to which I have denoted $100 since 
she shook me up for it; and Dr. Edward C. Green, senior 
research scientist, Harvard Center for Population and 
Development Studies, director, AIDS prevention and research 
project at Harvard University.
    Now that you have sat down, Dr. Gootnick, we are going to 
ask you to rise and--we will ask you to rise, and we will swear 
you all in.
    [Witnesses sworn.]
    Mr. Shays. What we do is we swear in all our witnesses. You 
can swear or affirm, but raise your right hands.
    In 10 years as a chairperson, there is only one person we 
have never sworn in, and that was the good Senator in West 
Virginia. I chickened out, Dr. Green, I just couldn't do it.
    We will start with you, Dr. Gootnick, and then we will go 
to you, Dr. Gayle.
    Welcome. Let me explain, we didn't do too good a job last 
time, but we have a green light there on both ends. We leave 
them on for 5 minutes, and then we allow you another 5 minutes 
if you need it. But we have four on the panel, so it would be 
good not to go beyond the 10 minutes. I will interrupt you 
after that certainly. So welcome.

 STATEMENTS OF DAVID GOOTNICK, DIRECTOR, INTERNATIONAL AFFAIRS 
  AND TRADE, GOVERNMENT ACCOUNTABILITY OFFICE; HELENE GAYLE, 
 PRESIDENT AND CHIEF EXECUTIVE OFFICER, CARE USA; LUCY SAWERE 
NKYA, MEMBER OF TANZANIAN PARLIAMENT (MP, WOMEN SPECIAL SEATS), 
   MEDICAL CHAIRPERSON, MEDICAL BOARD OF ST. MARY'S HOSPITAL 
  MOROGORO, DIRECTOR, FARAJA TRUST FUND; AND EDWARD C. GREEN, 
 SENIOR RESEARCH SCIENTIST, HARVARD CENTER FOR POPULATION AND 
                      DEVELOPMENT STUDIES

                  STATEMENT OF DAVID GOOTNICK

    Dr. Gootnick. Thank you, Mr. Chairman. Mr. Chairman, 
Congresswoman Lee, members of the subcommittee, thank you for 
the opportunity to discuss GAO's recent report on prevention 
funding under PEPFAR.
    As you know, the May 2003 leadership authorized PEPFAR; 
established the Office of the Global AIDS Coordinator, or OGAC; 
and established the GHAI account as the primary funding source 
for PEPFAR. The act also endorsed the ABC approach, recommended 
that 20 percent of the funds under the act support prevention, 
and requires starting in fiscal 2006 that one-third of 
prevention funds be spent on activities promoting abstinence 
until marriage.
    Our report reviews PEPFAR prevention funding, describes 
PEPFAR strategy to prevent sexual transmission of HIV, and 
examines key challenges associated with the strategy. In 
addition to document review and analysis, we present the 
results of structured reviews with key U.S. officials or 
country teams in each of the focus countries who are 
responsible for implementing PEPFAR programs.
    Regarding our findings, PEPFAR prevention funding in the 
focused countries rose by more than 55 percent between fiscal 
2004 and 2006, increasing from roughly $207 to $322 million. I 
note that our figures differ somewhat from those presented by 
Ambassador Dybul and would be happy to discuss that in the Q 
and A.
    During this time the prevention share of focused country 
funding fell by about one-third, bringing it into alignment 
with the act's recommendation that 20 percent of PEPFAR funds 
support prevention.
    The PEPFAR preventing strategy for preventing sexual 
transmission is largely shaped by the ABC approach, Congress's 
one-third abstinence-until-marriage spending requirement, and 
local prevention need. OGAC adopted broad principles associated 
with the ABC model.
    Mr. Shays. Doctor, why don't we move the mic a little to 
the left because you pronounce Ps very well.
    Dr. Gootnick. OGAC adopted broad principles associated with 
the ABC model, directing country teams to employ best practices 
coordinated with national strategies and focused countries, 
integrate across A, B and C activities, and be responsive to 
the key drives of the epidemic and local cultural norms in each 
country.
    To meet the spending requirement for fiscal 2006, OGAC 
directed that each focus country team, amongst other things, 
direct at least half of their prevention funds to the 
prevention of sexual transmission and within that spend $2 on 
AB programs for every dollar spent on what OGAC refers to as 
condoms and related prevention activities. Of note, activities 
that support IV drug, alcohol reduction and others are 
considered under condoms and related prevention activities. 
Seven focus country teams, primarily those with smaller PEPFAR 
budgets, received exemptions from this requirement.
    Regarding key challenges, although several teams noted the 
importance of promoting abstinence, more than half of the focus 
country teams reported that the spending requirement limited 
their ability to design prevention programs that were 
integrated across A,B and C, and most teams reported that 
fulfilling the spending requirement challenged their ability to 
respond to the local conditions and social norms in their 
countries.
    Between fiscal 2005 and 2006, funding in the focus 
countries for abstinence-until-marriage programs rose from $76 
to $108 million. During the same interval, condoms and related 
activities and prevention of mother-to-child transmission 
programs in these countries had roughly level funding. These 
program shifts allowed OGAC to project that it will meet 
Congress's one-third abstinence-until-marriage spending 
requirement. However, to meet the requirement for fiscal 2006, 
seven countries planned declines in PMTCT funding that ranged 
from roughly 5 to over 60 percent and seven projected cuts to 
programs aimed primarily at high-risk activities in vulnerable 
populations. These cuts ranged from 7 to over 40 percent.
    Finally, as a matter of policy, OGAC also applied the 
spending requirement to certain USAID and HHS funds despite its 
determination that by law the requirement applies only to funds 
appropriated to the GHAI account. These non-GHAI funds are a 
small part of the focus country prevention budgets; however, 
they represent more than 80 percent of U.S. prevention dollars 
for five additional countries, India, Russia, Zimbabwe, Malawi 
and Cambodia were also held to OGAC's policies on the spending 
requirement. This decision could especially challenge these 
country teams' ability to address local prevention needs.
    Our report recommended that OGAC collect and report 
information on the effects of this spending requirement on its 
programs and ask Congress to use this information to assess how 
well the requirement supports the act's key goals.
    GAO also recommended that OGAC use this information to 
reassess its decision to apply the spending requirement to 
PEPFAR funds in the nonfocus countries as previously mentioned.
    In commenting on our report, OGAC acknowledged that 
countries face difficult tradeoffs with their prevention 
programs, and Dr. Dybul reiterated that this afternoon. They 
agreed with our recommendation to collect and report 
information on the spending requirement; however, they did not 
agree that the requirement should be applied only to the GHAI 
account.
    Mr. Chairman, this concludes my statement. I am happy to 
answer any questions you or members of the subcommittee may 
have.
    Mr. Shays. Thank you very much, Dr. Gootnick.
    [Note.--The GAO report entitled, ``Global Health, Spending 
Requirement Presents Challenges for Allocating Prevention 
Funding Under the President's Emergency Plan for AIDS Relief,'' 
may be found in subcommittee files.]
    [The prepared statement of Dr. Gootnick follows:]

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    Mr. Shays. Dr. Gayle.

                   STATEMENT OF HELENE GAYLE

    Dr. Gayle. Thank you, and thank you very much, Mr. 
Chairman, Congresswoman Lee, and thank your subcommittee for 
the opportunity to join today to consider issues related to HIV 
prevention programs funded by the President's Emergency Plan 
for AIDS. We clearly feel that ensuring PEPFAR achieve its 
success in reducing HIV rates while we continue to focus on 
equitable treatment and humane care for those already infected 
is a key critical challenge for U.S. policymakers.
    Organizations like CARE who implement programs at the 
country level share your commitment to make sure that we use 
these resources in the most effective way as possible. We feel 
we owe that to the people in those countries and clearly to the 
U.S. taxpayers who make these resources available.
    We applaud the focus on prevention because clearly while 
treatment is critical, we can't treat our way out of this 
epidemic, and we really do need to think about how we are using 
the resources to keep people from getting infected to begin 
with. And we know that without effective prevention strategies, 
the numbers of infected individuals will continue to grow.
    We are here because we feel strongly that PEPFAR and the 
U.S. Government have shown real leadership and have contributed 
major resources and critical momentum to prevention, treatment 
and care, and we know that the program has already saved 
countless lives and provided much-needed support to 
communities, and we strongly support the continuation of this 
vital initiative beyond 2008. And so we are here today because 
we believe in the program, believe that it has a strong role, 
and want to provide instructive feedback.
    I would just say--and that feedback, that comes, from our 
experience, at the field level so that this program can be 
strengthened.
    Just say from the outset there was a lot of discussion, the 
first panel, about the ABC approach and whether this is the 
right approach. And I think we would go on record saying that 
we strongly believe that a behavioral approach, approach that 
changes people's risk of acquiring this infection or avoids it 
altogether, is the right approach. And so ours is not an 
argument about the merits of an ABC approach, but rather a look 
at how the current legislation may be construed in ways that 
don't allow for a balanced approach to the use of an ABC and 
behavioral change approach.
    And I also say this as somebody who worked in the U.S. 
Government for 20 years and was responsible for developing 
program guidance, and understand that what may be written at 
one level has huge implications in how it actually gets 
translated at the country level. So it is with that perspective 
that I want to talk about some things that we think would 
really help and make more effective the current program and 
make a bigger difference in lives.
    So I want to talk about, first of all, the importance of 
being able to more flexibly implement the current guidance to 
best respond to the needs at the country level; that we feel 
that the issue of--as a result of vulnerability of women and 
girls must be even more strongly focused on; that it is 
important that a focus on engaging other highly vulnerable 
populations is incorporated; look at the better need to 
integrate efforts to address underlying determinants that drive 
or compound vulnerability to HIV; and then finally to look at a 
greater commitment to look at the impact and the evaluation and 
long-term sustainability of this program.
    So I will try to be brief. I have a written statement that 
goes into much more detail. But our first point, that in our 
experience on the ground and resources for countries throughout 
the developing world, the PEPFAR country teams responsible for 
interpreting program guidance have articulated prevention 
policies and programs with a strong AB preference, leaving 
little room and funding for integrated local responses, HIV-
AIDS prevention programs. And again, we understand that this 
may not be the intent, but the experience on the ground 
suggests that this is a real issue.
    Let me just give you one example from our many 
conversations with CARE field staff in preparation for this 
hearing. In one of the PEPFAR focus countries with a 
generalized epidemic, our country office approached the PEPFAR 
country team with an innovative proposal to work with sexually 
active youth who were exchanging sex for money. Our proposal 
would have provided treatment for sexually transmitted 
diseases, training for alternative livelihood so that youth 
would not have to exchange sex for livelihood and for money, 
and a variety of--a more comprehensive approach to address 
these issues.
    This proposal was turned down for AB prevention funding 
because it was seen as not having a focus on those two 
elements, and I think highlights the fact that there is a real 
difficulty and a bias that works against having a comprehensive 
approach in the way that programs are actually implemented in 
the field because the funding categories of AB and other often 
end up being applied in a very rigid fashion.
    We have other examples of how this interpretation of the 
need to partition funding works against a more comprehensive 
approach, and as I stated in the beginning, our strong feeling 
is that all of those components are important, and it is only 
through having a comprehensive approach, a truly comprehensive 
approach, that the prevention efforts can be most effective.
    We believe that countries left to make the decisions, that 
have the freedom to make their own decisions that meet the 
needs of their country's circumstances, will, in fact, apply 
the funds in a way that provides for a balanced approach, and 
that countries don't need to be dictated to about the 
percentage of resources that are used for any particular 
strategies. So we believe that countries left to their own 
wisdom will, in fact, make good use and make--and use a 
balanced approach in their effort.
    Second, in sub-Saharan Africa, women represent 60 percent 
of those infected with HIV and 75 percent of infections between 
the ages of 15 and 24.
    Women and girls in Africa are well served by the ABC model 
only when they are free to make choices about abstaining from 
sex, or choosing to remain in a relationship where faithfulness 
is meaningful, or to access condoms and negotiate their correct 
and consistent use.
    But wherever women cannot control the sexual encounters 
they engage in, either for reasons of rape, abuse, gender 
disempowerment, economic dependency and cultural practices, ABC 
in its current formulation is significantly more problematic. 
And we have a lot of examples from countries that have high 
rates of rape and sexual exploitation where girls report that 
they feel compelled to exchanges sex for food.
    So clearly a message that focuses on abstinence and being 
faithful misses the point of the circumstances of these women 
and their lives. And so having a focus that really addresses 
the needs of women and the circumstances in which they find 
themselves is critical.
    I just give one quote, a predicament of one African woman 
interviewed by CARE which is all too widespread. She said, I am 
a widow and have no family around me except my small children. 
People in the community know I am poor and alone and thus more 
vulnerable. As I have no one to protect me and no money, I am 
often forced to provide sexual favors to officials, military 
and even my brother-in-law.
    We know that the OGAC has given more support to the issue 
of including gender issues, but we feel that needs to be a much 
stronger focus, recognizing that the ABC approach alone does 
not take into consideration the entrenched cultural and social 
norms that drive women's vulnerability. But we know that a 
difference can be made, and particularly when more focus is 
placed on changing male behavior.
    Again, to illustrate, an African man recounted the 
following to CARE field staff: My wife was raped, and I threw 
her out of out of the house. A neighbor helped her and talked 
to me, but I refused to listen to that woman. Later the men 
from the association came to talk to me. They explained what 
had happened, and it wasn't my wife's fault. They encouraged me 
to take her back into the home, and I did.
    So we know that, in fact, that by focusing on men's 
behavior at the same time, that we can have an impact on making 
a difference in the circumstances that affect the lives of 
women.
    Third point, the risk of HIV infection is significantly 
higher among certain vulnerable populations, including sex 
workers, injection drug users, men who have sex with men, and 
prisoners and sexually active adolescents. In many countries 
CARE HIV-AIDS and reproductive health programs reach sex 
workers and those engaged in transactional sex through 
interventions designed to reduce the risk of infection or 
identify activities to expand livelihood activities. PEPFAR's 
funding is often supporting too little and too little 
innovation in prevention programs among vulnerable populations.
    And in view of the time, I won't go into a lot of detail 
other than to say that I think the focus on vulnerable 
populations has to be included in that regard. And we think 
that the antiprostitution pledge is particularly 
counterproductive in the fight against HIV-AIDS.
    Our fourth point is that as we look toward PEPFAR 
reauthorization----
    Mr. Shays. Is this your final point? Because we need to 
conclude here.
    Dr. Gayle. Yes.
    It is important to learn from experience to date and begin 
to articulate components of a truly comprehensive HIV 
prevention policy that looks beyond the ABC formula and also 
addresses the broader underlying issues linked to HIV 
vulnerability and related issues.
    In that regard we look at issues of poverty, gender 
inequality and livelihood, understanding that all of that can't 
be funded through PEPFAR, but a better approach to integrating 
sources of U.S. funding, like food, nutrition, agriculture and 
economic growth resources so that those components can be 
integrated with prevention will clearly make a huge impact on 
the effectiveness of prevention programs.
    And I won't go into detail in the final one only to say 
that evaluation of this program and looking at the long-term 
impact of sustainability is also going to be critical.
    So I will just close there and look forward to your 
questions.
    Mr. Shays. You will have plenty of time to elaborate on any 
point in your statement and questions.
    [The prepared statement of Dr. Gayle follows:]

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    Mr. Shays. Dr. Nkya, you are most welcome here. And the 
only thing that concerns me is when I saw you in Africa, you 
had a smile on your face. You look too serious to me. I need to 
see that smile.
    This is a wonderful opportunity for us to have you here, 
and I just want to say before you speak, I don't want to put 
pressure on you, but our visit to Africa was made very special 
by getting to meet you. You are a remarkable person, and you 
honor us with your presence, and it is lovely to have you here.

                 STATEMENT OF LUCY SAWERE NKYA

    Dr. Nkya. Mr. Chairman, Congresswoman Ms. Lee, members of 
the subcommittee, I am honored to be here to speak on behalf of 
the African continent, and more specifically for my people from 
Tanzania.
    Mr. Chairman, before I discuss or give the evidence of what 
is happening with PEPFAR funding in Tanzania, I would like to 
give a few statistics of information about the epidemic in 
Tanzania.
    The AIDS Tanzania epidemic was first recognized in Tanzania 
in 1983 with three cases from the northwestern part of Tanzania 
called Kagera region. Within 3 years, the epidemic had spread 
throughout the whole country. That means it assumed a disaster 
proportion, and that is why in the year 2000 our President, 
when launching the AIDS policy, announced that AIDS was a 
national disaster in Tanzania.
    Mr. Chairman, I would like to bring to the attention that 
there is only 1 case out of 14 of AIDS cases in Tanzania who 
are reported to the nationalized control program, which is 
charged with the following of the money that are in the 
epidemic in Tanzania. That means that the statistics which are 
released are really, you know--and the reporting, and they are 
downplaying the epidemic and the proportion of the epidemic in 
the country.
    Out of all the cases reported, they referred that the peak 
of the epidemic is between 20 and 49 years that contributes 73 
percent of all the AIDS cases in the country, which means that 
this age group has been infected during adolescence or during 
their youthful years; that is, between 15 and 20 years of age. 
Then 10 years later that is when the epidemic starts showing 
up.
    Another point to take, to note, is the, you know, 
preponderance of----
    Mr. Shays. Let me ask you to put the mic a little closer to 
you. Just a little.
    Dr. Nkya. Is the early age of infection in women. The peak 
is between 20 and 29 years. That means women are infected at a 
very young ages compared to male counterparts, and that married 
people contribute 56 percent of all the cases of AIDS which are 
reported in the country as compared to the 32 percent of the 
singles.
    And the currently AIDS infection in Tanzania now is 7.7 
percent. This does not mean that the prevalence rate has gone 
down, but it is because it is based on blood donor, 
surveillance reports, which have proved that people now who are 
going go to donate blood have known about HIV-AIDS, so a person 
who suspects himself as being infected will not go. So this has 
brought down the infection rate.
    Let me tell you that we aimed at treating only 1,200 people 
out of 2,000 who are infected, but this is only in urban areas, 
and the legality is if your city or county is less than 200 
percent--200, that means a lot of people infected who could be 
healthy and lead a meaningful life--are denied opportunity for 
treatment. I don't know who brought in this cut point, but it 
is there.
    Let me say that the initial response is good, and I do have 
a very good HIV prevention strategy which includes ABC, plus 
other contributing factors like using the same instruments, 
ear-piercing and injections, and more on cultural behaviors and 
beliefs which contribute to the, you know, spread of the HIV-
AIDS.
    Now, what about my experience now with PEPFAR fund. And I 
am going to talk in relation to for trust fund.
    Mr. Shays. Your experience with what?
    Dr. Nkya. With PEPFAR funding program, the AB program.
    I am going to talk about my experience with FARAJA Trust 
Fund, which is an agency which I am directing. Before I started 
working with Deloitte through a program called ISHI--ISHI means 
live. It was a campaign which was targeting young people in 
Morogoro municipality with one message, that you should wait 
until marriage, and if you cannot, you can use a condom and 
engage in dialog.
    Dr. Nkya. Yes. The message is this: It means wait, don't be 
afraid. You know, engage him in a dialog or her in a dialog, or 
abstain. If you cannot, use a condom.
    That was the message. And you know, we produced a lot of 
teachers with the message. And it was all over the radio 
program, television programs, even the national television. 
Unfortunately during the last session of the Parliament, this 
message was banned from being transmitted through our 
television programs in Tanzania.
    Dr. Nkya. It was a successful program, it was a 1-year 
program. We had more than 7 million shillings from Deloitte. 
And it give the youth an opportunity to discuss openly about 
HIV/AIDS, to get access to condoms, the few condoms which I had 
because we could not access new condoms through the ministry 
because they were not available, there were no funds.
    And then the second message came in 2005, 2006 through 
Family Health International. Now the message changed, it was 
now AB, that was abstain or change your behavior. That was the 
message that was being given to the young people. Now what was 
the reaction? The reaction was very confusing. The young people 
would come to us and ask us, are you going mad? It was a bit 
embarrassing. You have been advocating condom use, behavioral 
change and abstinence where it is applicable, but now you 
change and say OK guys, it is time to be more realistic, 
abstain from sex until you get married--as if everybody's going 
to get married--or change your behavior, be faithful in 
marriage.
    So several questions came up. The first question was, what 
will happen to the sexually active young people who are HIV 
positive? What will happen to the couples who are HIV positive 
if free condoms--because many people in Tanzania are poor--if 
no free condoms are available? They're asking me, you know, 
have you changed the behavior and the culture of the people 
whereby, you know, rich men, especially affluent men, in the 
community that they are rich and influential, the number of 
concubines or sexual partners they're going to have, they came 
to ask me, you know, don't you know, mom, that the problem here 
is poverty, not even, you know, we being promiscuous.
    And this brought me back to the project which we started in 
the brothels. It is one of the biggest brothels where a lot of 
young women were in the 1990's, and I talked with one and asked 
her what is your problem, why do you have to leave your home 
and come to this place, which is filthy and they're being 
abused by men. She said, look here--they used to call me 
mother-in-law--mother-in-law, look here, it is better to die 
slowly than to die of starvation to death, and better off dying 
10, 20 years to come if the message is this, rather than dying 
today because the 10 years will give me time, first of all, to 
work and build a house for my children, and give enough time 
for my children to grow up and to become self-reliant, and also 
be able to purchase a farm. And then very slowly given enough 
time to repent of my sins, that's what they told me.
    Then probably, if I would give another example, another 
example is about a young girl who is 15 years old and she has a 
child. This woman, this girl asked how come she have a child. 
She told me that she was forced into marriage by her father, 
and that is, you know, perfectly in order, depending on the 
culture of our people in Tanzania, to marry a man as his 
official wife, and when this man died, she was forced to be 
inherited by the older brother of the dead man that she managed 
to run away and escape.
    Now what was her refugee? How could she leave with two 
children? So she had to engage in commercial sex work in order 
to live. And now I'm talking to her, telling her now, you see, 
if we check you--you come for physical, and we refer to you as 
either negative or positive, you should be abstaining from sex. 
Then she asked me, what am I going to do? How am I going to 
feed my children? My mother also expects me to support her from 
where I am now.
    That's the issue, Mr. Chairman. Let me say that the 
approach and the policy of AB does not take into consideration 
the culture of the people in the developing countries. It does 
not take into consideration the socioeconomic situations, 
things like poverty.
    Let me tell you that even empowering women or gender 
empowerment will never succeed if we don't address the issue of 
poverty, especially among women. This is evidenced by a program 
I conducted in a brothel whereby I was able to empower those 
woman economically, and we managed to remove more than 67 
percent of those women from prostitution, they are living, and 
their children are now going to school.
    Mr. Chairman, I have a lot of testimony, but----
    Mr. Shays. Well, maybe we'll get some of your testimony 
from the questions, but I remember your conversation with us, 
and as you--this brothel, as I remember, had literally hundreds 
of women, didn't it?
    Dr. Nkya. There were about 450 women, and we managed to 
rescue 270 women who were HIV negative to stop prostitution, 
and they moved back into their homes. The remaining, we were 
able to give them some money so that they could take care of 
themselves. Although they were positive, they could do some 
work, ideas to get food, to meet their present medical 
requirements and to feed their children. And eventually, as I'm 
talking today, Mr. Chairman, the brothel has been demolished, 
and these women now are living, they are respected and they're 
living.
    So that is a living example which has been by many people 
and organizations in Tanzania and some organizations from the 
countries that empowering women should complement economic 
empowerment because poverty is the basis of HIV. HIV is 
epidemic in our countries. Whether you are infected or not 
infected, you are in the rural area or in the urban area, if 
you are poor, you are going to engage into behavior which is 
going to put you into risk of getting infected. I'm not 
forgetting that.
    44 percent of our population is young people. That means 
these young people, as we have seen in the statistics here, 
they are more vulnerable than the others. So let's say that 
they're all vulnerable to getting HIV infection. So telling 
them to abstain, that is not really going to hold water, and 
backed by the fact that we did the survey in Morogoro in year 
2000 and year 2003, whereby we found that the minimum age of 
sexual activity started from 10 years, and for some were 9 
years of age.
    So given that basic fact, and I think, you know, it would 
be better off if HIV prevention strategies, that means 
including AB plus the other cultural factors, and economic 
factors which are contributing to this plague of HIV/AIDS.
    Mr. Shays. Well, we will get into some of this in the 
questions that Ms. Lee and I will be asking. So thank you for 
your testimony.
    I'm struck by the memory that as you went to this brothel 
to deal with these women, as I recall, your husband, who 
traveled, got a note from one of his friends saying your wife 
has become a prostitute. He didn't quite understand the role 
you were playing. You are obviously a magnificent lady.
    [The prepared statement of Ms. Nkya follows:]

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    Mr. Shays. Dr. Green.

                   STATEMENT OF EDWARD GREEN

    Dr. Green. Thank you. Mr. Chairman, members of the 
Government Reform Committee, thank you for inviting me to 
participate in this important hearing on AIDS prevention and 
PEPFAR. I'm a senior research scientist at the Harvard Center 
for Population and Development Studies.
    For most of my career I have not been an academic. I've 
worked in less developed countries as an applied behavioral 
science researcher and as designer and evaluator of public 
health programs, mostly under funding of USAID. I've worked 
extensively in Africa and other resource-poor parts of the 
world. I've worked in AIDS prevention since the mid 1980's, at 
which time I was working in the field of family planning and 
contraceptive social marketing in Africa and the Caribbean, and 
I've served on the Presidential Advisory Council for HIV/AIDS 
since 2003.
    I might add that I worked with Dr. Nkya in 1984 in Morogoro 
in that very project for sex workers. We were helping them not 
get infected or pass on infections, treat their STDs, and 
provide income generating skills if they wanted to get out of 
sex work, which the great majority did.
    I would say that obviously abstinence is not the very 
relevant message if you're an active sex worker, but then 
neither are condoms and clean syringes, the primary message 
that you would bring to primary schools.
    Since my time too is very short, let me just cut to the 
chase. And I feel that amending the 2003 act that requires that 
33 percent of PEPFAR prevention funds be spent on abstinence 
and fidelity programs, moving this would be a bad move, 
removing this earmark would remove the essential primary 
prevention foundation from the U.S. Government response to the 
AIDS pandemic. It would leave only risk reduction, which is 
different in intent and effectiveness from true prevention.
    A risk reduction approach assumes that behavior 
contributing to morbidity and mortality cannot be changed; 
therefore, the best we can do is to reduce risk. And this was 
our strategy with those sex workers in Morogoro. Risk reduction 
alone has never brought down HIV infection rates in Africa. 
This conclusion was reached by three separate studies under the 
rubric of the USAID funded ABC study in 2003, and later. It was 
also reached by a U.N. AIDS study of a 2003 study condom 
effectiveness review by Herston Chen, and it was the conclusion 
implicit in the UN/AIDS multi-site African study published in 
2003.
    Prevention based on risk reduction had some early success 
in Thailand, and later in Cambodia, but never in Africa, or at 
least outside of the few high risk groups. Now PEPFAR and USAID 
lead the world in AIDS prevention, promoting a balanced and 
targeted set of interventions that include Abstinence, Being 
Faithful and Condoms for those who cannot or will not follow A 
or B behaviors. And I'm the person who said this is in spite of 
formidable and continuing institutional resistance to change, 
and maybe we can talk more about that.
    Removing primary prevention from this mix by removing the 
present earmark would almost certainly return AIDS prevention 
to the era when HIV prevalence continued to rise in every 
country in Africa, with the exception of Uganda and Senegal, 
the first two countries in Africa to implement ABC programs. 
Since then, ABC programs and changes specifically in A and B 
behaviors, especially in B behaviors, as has been said earlier, 
which is measured in the decline in the proportion of men and 
women reporting two or more partners in the last year, are 
credited with reducing HIV prevalence not only in Uganda, but 
in Kenya, Zimbabwe and Haiti, and possibly in Rwanda. These 
last three countries' successes were all the more remarkable 
considering the political and economic devastation they've 
suffered.
    As was mentioned, a consensus statement published for the 
2004 World Aids Day special issue of the Lancet proposed that 
mutual faithfulness with an unaffected partner should be the 
primary behavioral approach promoted for sexually active adults 
in generalized epidemics. Abstinence or the delay of age of 
sexual debut should be the primary behavior approach promoted 
for youth. This represents a fairly marked departure from many 
previous prevention approaches which emphasized condom use 
almost exclusively as the first line of defense for sexually 
active adults for all types, in other words, regardless of the 
country, the culture or the type of epidemic. This statement 
was endorsed by over 150 global AIDS experts, including 
representatives of five U.N. agencies, the WHO, the World Bank, 
as well as President Museveni, and two of the authors were 
myself and Dr. Gayle.
    A growing number of public and international health 
professionals recognized the previously missing AB component of 
ABC as logical, sensible, cost effective, sustainable, 
culturally appropriate interventions for general as distinct 
from high risk populations. Moreover, the evidence is clear 
that these components work, and that risk reduction alone has 
not lead to a simple success in generalized epidemics.
    I wish I had more time to present more evidence, I thought 
we were going to be kept on our 5 minutes.
    For example, DHS, Demographic and Health Survey data showed 
that higher levels of AB behaviors--and it's assumed by many 
that we already see that, including people who work in the AIDS 
field ought to be familiar with the data. For example, only 23 
percent of African men and 3 percent of African women reported 
multiple sex partners in the last year, according to the most 
recent DHS surveys. Among unmarried youth 15 to 24, only 41 
percent of young men and 32 percent of young women in Africa 
reported premarital sex in the last year. This means that most 
African men and women practice B behaviors, or do not have 
outside sexual partners, and most unmarried African youth do 
not report sexual intercourse in the past year.
    I hate to use the controversial A word, abstinence, but 
that's what surveys show. And I wish we could take away the 
word only after abstinence.
    Moreover, the trend in Africa is toward higher levels of A 
and B behavior, it is toward incrementally lower HIV 
prevalence. HIV prevalence is an average of 7.2 percent for 
Sub-Saharan Africa in 2005, compared to 7.5 percent in 2003. I 
mention this because critics of the African ABC model often 
depict African men in particular as incapable of monogamy or 
fidelity, which is simply not true. When critics of fidelity 
and abstinence programs argue that these behaviors sound nice 
but don't get the reality of Africa, one only needs to look at 
the available behavioral and epidemiologal evidence--this is 
from DHS, studies by Population and Services International of 
Family Health International, a number of USAID recipients of 
funds.
    In conclusion, I hope Congress will take no actions that 
would seriously undercut the one major donor agency in the 
world that is conducting effective AIDS prevention, the 
generalized epidemics by in effect removing the very 
interventions that have been proven to have the most impact. I 
believe that the simple effect of the African model of AIDS 
prevention is still so new and different from the old way of 
doing things that without some direction from Congress, the 
bureaucracies involved in guiding implementation would probably 
fall back into old habits and once again limit AIDS prevention 
to its reduction to condoms, drugs and testing. These three are 
all necessary, but A and B is the missing part.
    If I could just take a moment to answer the question that 
you were asking the government panel, why not simply leave 
allocations to the countries themselves. We had an example of 
that happening in 1998, the Ministry of Health in Jamaica 
convinced USAID, they said basically we feel we have the 
expertise in our government and our NGO's, give us the money 
and we'll give you the results. After 5 years, we'll account 
for every dollar to see how we do results-wise. And what they 
did, what Jamaica did is they developed a program very much 
like that of Uganda or Senegal, it was a balanced ABC program, 
and I was one of the three American evaluators, and STD rates 
were coming down, and it seemed like HIV rates were coming 
down, and it was one of the better programs I've seen in 
developing countries.
    I think where the problem is, Mr. Chairman, is with us, is 
we technocrats from the United States and Europe, we're used to 
the American model of AIDS prevention which is focused on MSM 
and IDU, focused on high risk groups. And so if you come from a 
family planning background the way I do and you're used to 
preventing contraception, which I am and USAID is 
institutionally, and all of a sudden, you find out that Uganda 
and some other countries are quietly doing something a little 
bit differently and having results, it takes a while to change 
your thinking and to change what the bureaucracy does. And when 
you think of all the grantees, the contractors and what they 
do, what they do best, it takes some change. So I really think 
that if the earmark were removed right now, we would go back to 
the AIDS prevention before 2002, and we wouldn't be having as 
many successes as we now have. Thank you.
    Mr. Shays. Thank you, Dr. Green.
    [The prepared statement of Dr. Green follows:]

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    Mr. Shays. We're going to start with Ms. Lee.
    Ms. Lee. Thank you very much, Mr. Chairman.
    Let me first say once again, thank you for this hearing. 
It's very important. And as I listen to the testimony, the only 
thing I can think of is we're talking about saving lives right 
now, and finding the best way to do that and to help people 
live longer lives until we do find a vaccine or a cure. And I 
need to say up front that I think we need to repeal this 
earmark. I intend to do everything I can do to try to get that 
repealed.
    Dr. Green, now you're at Harvard University, and I 
appreciate Harvard and know of your good work and Harvard's 
good work throughout the world. And I have to ask you, though, 
in one who believes that ABC makes sense, abstinence, be 
faithful, use condoms, why in the world would you believe that 
ABC is not what we're talking about when we talk about 
abstinence, be faithful, use condoms, I mean, we're talking 
about a balanced comprehensive approach. And with this earmark 
being what it is, we have seen in and GAO has indicated that 
this is probably hindering our efforts in the prevention arena. 
And let me just say, I was at the last AIDS conference in 
Toronto, the rest of the world, quite frankly, disagrees with 
what you're saying, Dr. Green, the rest of the world 
understands and gets it. The rest of the world believes that 
they know how to develop country-specific plans that come up 
with their specific ways of addressing prevention, care, 
treatment. And so why would we not listen to what works in 
countries and not be as heavy handed in our approach?
    Dr. Green. With all due respect, that's exactly what I'm 
doing, my rethinking AIDS prevention in 2003 was looking 
specifically at the first five or six countries to experience 
prevalence decline. I also have to say, with all due respect, 
that the people who attend the global AIDS conference are not a 
cross-section of Africa, Asia, Latin America--this is not the 
best of the world.
    Ms. Lee. Well, Dr. Green, what countries do you think would 
not want to see the earmark repealed?
    Dr. Green. What countries would not want to see it 
repealed? Who would you ask in those countries? If you put it 
to a vote of the people, the majority of the population, I'm 
certain that all of the countries would want to keep the 
earmark there if they understood that----
    Ms. Lee. They knew they could get some money.
    Dr. Green. No, if they understood that AIDS prevention 
would go back to risk reduction only.
    The head of the National Aids Committee for Kenya 2 or 3 
years ago posted a complaint on an AIDS discussion group on 
line that the ministry--that the government of Kenya had 
received an additional $10 or $15 million for AIDS prevention. 
And part of what the government wanted to do was have a program 
to reach kids before they become sexually active, to promote 
abstinence or delay of sexual debut, not abstinence only, but 
to include. And they were told no, this is money from the U.S. 
Government, it has to be spent on condoms. And he wrote a 
letter to complain, and I asked if I could put his letter in my 
book, which I did. I, again, say I think the problem is with we 
technocrats--and I mean European and American experts who work 
in AIDS, we're used to thinking in terms of the American 
epidemic, the European epidemic, high risk groups--which are 
some of the first groups we went after in Africa and the 
Caribbean, I was working in the Dominican Republic in the mid 
`80's. We went after--we tried to reach sex workers and their 
clients. But again, if you look at the data, most Africans, 
most people everywhere are already engaged in primarily B 
behaviors, and young people are primarily engaged in A 
behaviors. I don't even like the word ``behavior change.''
    Ms. Lee. Dr. Green, all I'm saying is that the 
conditionality aspect of this, even telling a country that they 
must have a strategy that only uses condom as part of their 
strategy----
    Dr. Green. I'm glad you agree that's wrong.
    Ms. Lee. I'm talking about ABC; I'm talking about allowing 
countries to come up with their culturally specific, their 
scientifically specific, their gender specific, their overall 
approach to how they want to deal with this pandemic. So no, we 
shouldn't say----
    Dr. Green. I think we should do that, I think we should 
find out----
    Ms. Lee. I think we shouldn't say if we don't like the way 
you approach it. What I've heard--and again, I think that we, 
at the international AIDS conferences and throughout the year 
we hear from many, many people around the world who want to get 
rid of this earmark because of one point, they want to be able 
to be unencumbered by their approach to addressing this 
pandemic because it's so serious.
    And with regard to women, what happens to women? We all 
know what happens to women. We heard earlier, the empowerment 
of women, women's equity, gender equity, female condoms, all of 
these strategies.
    Dr. Green. That's part of the B strategy. If faithless men 
are infecting their wives, then it's the men's behavior that 
needs to change, and that's B.
    Ms. Lee. But what about women and the access to condoms? If 
a country or the United States has precluded the funding for 
that, what if women----
    Dr. Green. Well, they shouldn't.
    Ms. Lee. Well, the earmark, in many ways, precludes a 
comprehensive balanced approach.
    Dr. Green. I don't see it that way. There is a larger pie 
now to divide up than there was a year ago, 2 years ago, 3 
years ago. As I've been saying for some years now, as we have 
gained more to work with in AIDS prevention, let's not put all 
of our money into programs that have not worked in Africa and 
the Caribbean.
    Ms. Lee. I'm not talking about putting all of our money 
into programs that don't work. All I'm saying is why can't we 
just repeal the earmark and say to countries, develop whatever 
plan makes sense to address this terrible deadly disease. 
That's all I'm saying, period, dot dot.
    Dr. Green. I agree with the intent of what you're saying, 
but I think in practice what happens is poor countries ask for 
the program that they know that there is money for.
    Ms. Lee. Oh, Dr. Green, come on. You know how you're 
sounding, very patronizing. Countries have the ability--and 
I've spent quite a bit of Africa----
    Dr. Green. I lived there.
    Ms. Lee. Countries around the world have many unbelievable 
people who know how to address epidemics, pandemics, disease if 
only provided the resources and the support and the technical 
assistance. I can't believe that in any country at this point, 
if we didn't help develop and go in and do the things we need 
to do to support their efforts, that they couldn't be 
successful. So I can't buy the poor country notion.
    Dr. Green. Again, I agree with your intent. I wish there 
was some way to let these countries choose for themselves 
without imposing our priorities on them.
    Ms. Lee. Well, I think we can.
    Let me just say to Dr. Gayle, I want to congratulate you on 
the successful conference in Toronto, it was really quite 
successful, quite powerful. I've been to four, and intend to go 
to the next one in Mexico City. And as I was thinking about 
Toronto today, I said when in the world are we going to have an 
international AIDS conference in America? And then it dawned on 
me that we have certain travel restrictions for people living 
with HIV and AIDS that precludes us from having such an 
important conference in our own country.
    So I'm going to work with others to try to--again, I hate 
to keep trying to repeal stuff, but we want to get rid of that, 
too.
    You know, I mean, I think that the world is a small place 
now, and we need to figure out ways to work together. And for 
us not to be part of this conference and not to be able to have 
it on our own soil to me is just downright wrong and, quite 
frankly, it's immoral. I was proud to carry the American flag 
in a rally in Toronto. I knew I couldn't carry the American 
flag in a rally here in America at an international AIDS 
conference. Mr. Chairman, I think that's pretty bad and it 
doesn't bode well for our standing in the world.
    And so I just to want congratulate you and also just to ask 
you your take on--you heard what Dr. Green said about the 
conference in terms of who goes and who doesn't go. What is 
your take on the abstinence only policy, and by the rest of the 
world, the rest of the world that didn't come to the 
international AIDS conference.
    Dr. Gayle. Yes, thank you. And we appreciate you and the 
Chair's leadership in this issue. And I also appreciate your 
comment about repealing the travel restrictions. We really 
would love to see an international conference on U.S. soil 
again and feel that there's a real value to it because I think 
it goes along with the leadership role that the United States 
is playing. And that's why we feel so strongly about getting it 
right because we feel that not only are the resources that the 
U.S. Government contributes critically important, but the 
leadership role that the U.S. Government can play and does play 
is critically important. And so the consistency in that 
leadership role we feel is extremely important on all these 
issues.
    I would disagree, I think the International Aids 
Conference, I disagree with Dr. Green that the International 
Aids Conference is a wide cross section of people working on 
HIV at a grassroots level as well as the international arena. 
So while perhaps it isn't perhaps totally inclusive, 24,000 
people working on HIV from all different continents I think 
does speak to a pretty inclusive gathering. And we didn't take 
a poll on what people thought about the restrictions, but I 
think it's fair to say that there are concerns because not only 
does what the U.S. Government do impact U.S. Government 
funding, but again, the United States plays a strong leadership 
role. And so I think it does also influence other people's 
thinking about what is the right way to do things. And so what 
we do with our funding does influence the world, and I think 
sending a message to the world that we don't see this in a 
comprehensive way, that we do have biases, has an impact. And I 
think all efforts to really allow for countries to make 
decisions to have an integrated program, just like we talk 
about combination treatment, we also have to talk about 
combination prevention. There is no one-size-fits-all, it is by 
the ability to make programs that fit the country needs and 
country circumstances that we can have the most effect 
prevention response.
    And I would argue that as somebody who's been doing HIV 
prevention programs for over 20 years, I don't remember a time 
when we as public health professionals said that condoms were 
the only answers. So this idea of going back to that day, I'm 
not sure where that perception comes from. I think that the 
understanding and the evidence around what works for HIV 
prevention has evolved. And so I think it is not legislation 
that leads to the understanding that a comprehensive approach 
is right, it is evidence, it's the fact that we have growing 
evidence that this is the right approach.
    So I don't think the clock will be turned back, whether you 
think that it was there or not. I don't think that it is 
legislation that keeps people looking at a comprehensive 
approach, it's the evidence, it's the evidence that says this. 
And I think whether it's technocrats or whether it's the 
country level, it is a comprehensive approach that must move 
forward. And I don't think that it is a need for a proscriptive 
approach what is what will keep a comprehensive approach on the 
books and in our policies and in our program, it's the fact 
that we all know that is the best way to have an impact on 
prevention by doing it in an integrated fashion, doing it in a 
comprehensive way. The evidence is there, and I think that 
stands for itself.
    And I would just add that I do think that the issues that 
were raised around making sure that we address the other 
issues, the issues of poverty, the issues of gender and equity, 
we must do that in order to support a behavioral prevention 
strategy because people's behavior, individual behaviors occur 
in the context of social realities.
    Mr. Shays. Let me jump in here, I'd like to take some time.
    Dr. Green, first let me say you bring tremendous 
credibility to whatever position you take based on the work 
you've done for so many years. So even if Ms. Lee does not 
agree with you, it's important that we hear exactly what you 
think, and then kind of wrestle those out.
    I would like to know, coming all the way from Africa, what 
would be the most important thing that you would want us to 
know about the continent as it wrestles with this disease? And 
what is the biggest area that you would want, Dr. Nkya, to 
impress upon us so that I'm very clear as to the most important 
thing that you want us to know.
    Dr. Nkya. Thank you, Mr. Chairman.
    Coming all the way from Africa, I'd like to insist that 
AIDS is a disease of poverty. And it is compounding on the 
threat of disease, poverty, it is also compounding on the 
socioeconomic impact and even the physical well-being of the 
people, which also in turn compounds the vicious cycle of 
compounding poverty itself.That is one.
    Two; it is unfortunate that we in Africa, especially in 
Sub-Saharan Africa, we are always the recipients; we totally 
depend on external support on most of our intervention 
packages. So whoever comes with assistance in HIV intervention, 
they come with their own prescription for intervention package. 
Whether we agree to it or not, we have to adhere because we 
need the money. And it's unfortunate that we cannot even become 
a bit flexible to fit into our own, you know, what is really 
workable in our own environment.
    So what I would like to, you know, ask you or request from 
this package or from the funding is like what Congresswoman Lee 
was saying, that if countries were given the opportunity to 
choose and to plan for themselves, could it really have an 
impact on the spread of the disease? I'm saying yes. Yes, 
because, for example, in Tanzania, we recognize that women are 
very vulnerable. We know that when we are addressing ABC, and 
there are free condoms for those who want to use condoms and 
have the information, the impact is really good, but now we 
cannot produce condoms because most of the money for condoms 
came from the United States of America. So now we do not have 
access to free condoms.
    Money comes for treatment and for prevention for mother to 
child. It's unfair to just giving the women some medicine to 
prevent the child from getting infection at birth and while the 
child is newborn, but after that there is no form of support of 
counseling. So I would like to see more money being allocated 
to provide holistic HIV--I would like to see some money being 
allocated to provide holistic HIV/AIDS prevention package, like 
for primary schools, very young children we can talk about 
abstinence and behavioral change. For the grown up children, 
because we know, whether we want to talk about it or not, they 
are practicing sex.
    We should be able to give them more information about, you 
know, productive health, more information about behavior 
changes through life skills training, which is not really 
widespread in Tanzania and that's why we have so much AIDS.
    Mr. Shays. What I find myself wrestling with, and I'd like 
all of you to respond to it, and I'll start with you, Dr. 
Green, when I heard the first panel talk about basically a 
holistic approach, looking at all abstinence as well as condoms 
as well as be faithful and so on, what I'm realizing though is, 
from the testimony that we've heard from this panel, that we 
really separate them. And so I'm thinking, is it a crapshoot in 
a way? Do some students only get abstinence and some students 
only get condoms, and is it really an integrated program 
because of that? And you know, you, Doctor, are getting me to 
think that way, that if that's where the money is--first off, I 
believe that folks will go wherever the money is, I mean, 
they're going to design a program, we give them money they're 
going to design a program to be able to attract that money. Do 
you get the gist of my question, Dr. Green?
    Dr. Green. Did I get the question?
    Mr. Shays. Do you understand what I'm asking?
    Dr. Green. Not quite.
    Mr. Shays. OK, let me ask it this way. If we are mandating 
that a certain amount be for abstinence--there's going to an 
abstinence program that's provided, correct?
    Dr. Green. Yes.
    Mr. Shays. But I suspect in most instances, the abstinence 
program is not going to also tell you you can use a condom, and 
that you're going to see a program in abstinence. And that you 
might see a program that, you know, is providing condoms, but 
you don't integrate it. So it's not like what people are 
suggesting. You know, trying to persuade a young person about 
abstinence is the best way, but here is a condom if you're not 
going to go that route, it almost seems like a contradiction.
    Dr. Green. Well, I agree with your implicit criticism of 
compartmentalizing, you know, this program is for this and only 
this, and the B and the C are only for the--and that's not 
integration and that's not real life and that's not responding 
to people's actual needs. So I think we're in agreement there.
    I think the government panel testified that after the age 
of 14, that the B and C message are brought in. You know, if 
there is evidence that children are sexually active at age 10 
or 11 and that's their situation, you can't change it--I would 
try to change it--then you need to bring in condoms earlier. So 
I'm not in favor of abstinence only.
    You know, if we just look at the Uganda model, and we can 
look at the other models, Senegal and more recently Kenya and 
so forth, I didn't see much evidence of condoms only. I have 
pages of teachers books and student books from primary schools 
in Uganda, and condoms are part of the education. So there 
should be integration. I don't know that much about how PEPFAR 
is integrating, but that's the way it should be.
    Mr. Shays. Dr. Gootnick.
    Dr. Gootnick. Thank you. I think the particular lens that 
GAO can bring to this discussion is really two-fold. One, if 
you offer the U.S. Government implementers in the field, the 
USAID and CDC staff in the field some degree of candor and ask 
them how this spending requirement affects their programming, 
you'll get some interesting information. That's the first 
thing. And second----
    Mr. Shays. And the interesting information is?
    Dr. Gootnick. Well, the interesting information is that 
more than half of the respondents will tell you that while 
Office of Global AIDS coordinator will certainly allow an 
integrated program, an ABC program--and if Ambassador Dybul was 
here, I think he would tell you that these programs, the vast 
majority of them are integrated. But if you speak to the 
implementers in the field, they will tell you that program 
dollars in these different buckets has consequences, and that 
there are programs that could be much better integrated but for 
the spending requirement that the program works with.
    The second point is if you look at where the dollars have 
had to move, and the difference between 2005 and 2006 really is 
enlightening. And there will never be another set of data like 
the transition between 2005 and 2006 and that's because 2006 
was the first year that the one third abstinence requirement 
became law.
    So looking at what happened in the shift between 2005 and 
2006, it is informative that no other data set will be. And as 
I mentioned in my prepared remarks, if you look at in the 
aggregate, AB programs went up very significantly whereas 
prevention mother-to-child transition and condoms and related 
program activities remain level. If you look at a country 
level, you see some real tradeoffs that have been made there. 
If you look at a country like Zambia, you see that there has 
been nearly a 40 percent cut in condoms and related program 
activities at the same time that abstinence programs have 
risen. You see in that country also as you well know that sex 
workers, migrant populations, and other vulnerable populations 
are perhaps key to the epidemic there. You see that sexual 
transmission in discordant couples, in a couple where one 
individual is positive, the other is negative and may not know 
it, the rates of transmission in discordant couples are very 
similar to the rates of transmission in the general population, 
so----
    Mr. Shays. I'm not getting the point as to how that relates 
to my question.
    Dr. Gootnick. Well, the point is that an integrated 
program--the U.S. Government implementers will tell you that 
the counting of the money in the buckets of abstinence, 
faithfulness and condoms related programs does hamper their 
integration. And you will see, if you look at the dollars, 
considerable shifts in program dollars in order to meet the 
spending requirement.
    Mr. Shays. OK, thank you. Doctor.
    Dr. Gayle. Yes, briefly to add to that, I would agree our 
experience at the field level is that while the guidance, 
strictly speaking, does allow for an integrated approach, the 
way it's practiced inconsistently and the guidance that is used 
does bias programs often in an AB category where the preferred 
program would be to implement an integrated approach so that we 
do have in the field programs that end up being not integrated, 
only having one element or the AB approach not being able to 
integrate condom funding, and again, not because that is 
necessarily explicit, but the guidance is confusing, and it 
ends up being interpreted in the field in a very 
compartmentalized way.
    Mr. Shays. Does your organization provide all three, ABC, 
all three?
    Dr. Gayle. Right. But we're in 70 different countries. So 
at a country level, the guidance is applied differently. As an 
organization overall, yes, we definitely focus on a 
comprehensive integrated approach. But by country by country, 
the way the guidance is interpreted pushes people in one 
direction or the other, and compartmentalizes programs much 
more than the original intent would have been.
    Mr. Shays. OK, thank you.
    Dr. Nkya. But Mr. Chairman, my concern is this; whether we 
talk about ABC, but for poorer countries like Tanzania, you 
can, you know, violate the rule and talk about ABC. But there 
are many people who would like to use the condom, and young 
people cannot access condoms because they're not there. I go 
and ask the minister of health what is happening, we don't have 
condoms, we says we are not getting money from the United 
States of America to buy condoms----
    Mr. Shays. Let me ask you this; OK. You're not getting it 
from the United States, but you're not getting it from anyone 
either?
    Dr. Nkya. We're not getting it from anybody else because 
the others who are funding something like integration impact, 
and others have some other interests like working with other 
organizations, but initially, all the condoms in that country 
were being funded by the USAID from America. So now we don't 
access--for the past 5 years--4 years we don't access free 
condoms for anybody in that country.
    Mr. Shays. So I make an assumption that if condoms aren't 
available, we're basically transmitting AIDS. If condoms aren't 
available, sex--I mean, I have not yet known a society that's 
decided to give up sex. So what I make an assumption is, from 
your testimony--and it's pretty powerful because, unlike the 
others, you're there, you're working with young people all the 
time, and you're saying and testifying before this committee 
that condoms are not available. That is a powerful message 
because we know that is one way to prevent the transmission of 
AIDS. We could talk long and hard about whatever we want to 
talk about, the value of abstinence, but if in the end condoms 
aren't available and young people and older people are having 
sex, they are at huge risk. And what I'm trying to understand 
is why would it have to be, Dr. Green and Dr. Gootnick and Dr. 
Gayle, if we are saying it's an integrated approach, why can't 
it include all of the above? And why, in the end, are condoms 
not available? Are they that expensive that--so someone help me 
out here.
    Dr. Gayle. Well, I guess I would agree with the earlier 
statements, that in order to have the best chance at having a 
balanced approach is to let countries develop programs that 
meet their needs at the country level, and that countries make 
those decisions about what proportion gets spent on what part 
of the ABC approach based on what their greatest needs are. So 
that if condoms and condom shortage was the greatest need for a 
given country, that they have the ability to use resources for 
condoms. If, on the other hand, they had other funders that 
allowed them to use those resources for purchasing condoms, 
that more focus be put on the other parts of the approach, so 
that countries have the ability to make those decisions without 
having arbitrary proportions that need to be spent, and can 
develop a truly integrated approach.
    So I think the lack of funding for condoms is reflected by 
the inability too use resources to spend it on what countries 
need it for the most.
    Mr. Shays. I'm going to react to something--thank you. Dr. 
Green, I'd like you to react to--I'm going to tell you what I'm 
hearing and I'd like you to react to it.
    What I'm hearing is a better and more powerful message than 
I thought in support of abstinence programs. I thought that the 
first panel did a better job than I anticipated. You believe in 
this program and you carry a lot of weight; you've had 
tremendous experience and you do research and so on, so that 
carries weight with me. But I'm left with the fact that if it's 
a mutually exclusive issue--in other words, if you go the route 
of abstinence, you are not providing enough condoms, for 
instance, as one preventative way, then one, it isn't know an 
integrated approach. But No. 2, if I had my child--let's not 
use my child, let's just use any child, if they only had one 
choice, they were going to have an abstinence program but still 
have sex, I'd prefer they had a condom instead of an abstinence 
program and still have sex. I mean, so react to what I'm 
saying.
    Dr. Green. It seems like we always fall back into talking 
about abstinence versus everything else. Keeping in mind that 
both government panelists and I have reported, which is that 
it's part of reduction, it's not having--what drives epidemics, 
sexually transmitted epidemics whether heterosexual or 
homosexual, what drives these epidemics is having multiple 
concurrent partners. And what brings prevalence down at the 
population level is not having multiple concurrent partners.
    So I wish I didn't always have to be put in the position of 
defending abstinence--and we're leaving out the thing that 
works best. So having said that, how often have I heard African 
health educators and others say if it was--you know, it's not 
if it was only one program, they would say if it was only one 
behavior, I would want my child to abstain and not have sex 
using a technology that, if used consistently is 80 to 85 
percent effective in reducing HIV infection.
    The problem is that rarely are condoms used consistently in 
Africa, in the United States, anywhere in the world. I didn't 
want to bring this up because it just makes me even more 
unpopular than I probably already am to talk about 
uncomfortable data, but there is an unwanted and unfortunate 
correlation between populations where you find more condoms 
available and people use them more, and higher infection rates.
    The demographic and health surveys, we now have serologic 
data to go with behavior data, so we can easily cross tabulate 
those who are--we can look at the sero status of those who are 
practicing A, B and C behaviors. And the first countries we 
have evidence from from the demographic and health surveys--and 
I don't think these have been published yet because there are 
uncomfortable data--from Tanzania, from Ghana, from Uganda--I 
think there may be one other country--we see that condom users 
are more likely to be HIV infected than non-users. This is 
counterintuitive, it's not what we want, it's not where we put 
billions of dollars, but it may be because--it's probably 
because condoms are not used consistently usually, and second, 
there's a disinhibiting effect. If the message is you can do 
what you want, be sure to use American brand condoms, then 
people will probably take more chances than they would if they 
weren't using condoms. Again, this seems to be 
counterintuitive.
    Mr. Shays. One last question. I heard the data is 85 
percent; is that because they're not used properly?
    Dr. Green. 85 percent is about right.
    Mr. Shays. Basically, what you're saying is so someone is 
having sex with someone who had AIDS, by one out of ten, you're 
going to get AIDS even with a condom. But is that because 
they're not being used properly?
    Dr. Green. We don't know the reasons. It's probably more 
improper use. It's not being consistent; this is when condoms 
are used consistently, it's probably that they're not used 
correctly. In poor countries, you don't have good storage, 
condoms may be the wrong size. How often in Africa I see 
condoms made in Thailand, wrong size. There's product failure, 
in part, because they may be old condoms, expired and so forth, 
especially in poor countries.
    So those reasons are--those figures are pretty consistent 
every time. We knew this from family planning. Before the AIDS 
pandemic I worked in family planning; the condom was not one of 
the more effective methods of prevention----
    Mr. Shays. Let me do this; if any of the panelists want to 
just respond to any question I asked Dr. Green.
    Dr. Nkya. Mr. Chairman, I would like to comment. I would 
like to ask him, at that particular time when condom 
distribution was started, was there a survey, you know, a 
serological test to know who was positive and who was negative? 
Because when you start giving condoms, you don't know who's 
positive or who's negative. So when you started giving condoms, 
that's the majority of those people are already infected, but 
we are preventing infection. So that is my concern.
    And another thing about the storage, and the condoms being 
made in Thailand being shorter than, you know, the private 
parts of men in Africa it is true, but that is another 
aberration which I'm seeing that if someone wants to give us 
assistance and he goes ahead and orders condoms for us without 
taking into consideration of sizes of our people, that is 
another thing that I'm saying that I disagree with completely.
    The storage part of it, you know, you give the condoms. You 
don't give money for logistic support whereby you could be able 
to transport and store the condoms in the situation whereby 
they remain, you know, protective, that is another problem, 
because someone says I'm giving you condoms, I'm ordering them, 
not to take into consideration about the sizes, the needs and 
other logistical support which is needed to transport the 
condoms from where it is manufactured, and to the end point to 
where, you know, the beneficiary is. That is another problem. 
And that's why I support the idea that the developing countries 
should be given the opportunity to plan how to use the PEPFAR 
funds whenever the funds are available.
    Mr. Shays. Let me go to Ms. Lee. Oh, I'm sorry----
    Dr. Gayle. I was just going to make an additional comment. 
I agree with the comment that was made about the shortcomings 
of the survey which are cross-sectional data, and I think it 
needs to be put into broader context. It could be that people 
with condoms were already infected, it could be that by 
definition, those in the population are already at greater 
risk, so it's not surprising that the rates would be higher, 
but I think what it really points to is the fact of what we've 
been talking about, that it isn't one or the other, even condom 
use needs to be in concert with a focus on changing risk 
behavior to begin with. And I think most people in this 
business believe that it isn't one or the other and that they 
reinforce each other, and it's not just a condom message, it's 
a condom message that also talks about reducing risk behavior, 
reducing the number of partners. And it's by doing all of those 
things together that you have the greatest impact and are 
synergistic.
    So it is not one or the other, and that's, again, why this 
whole focus on being able to have a comprehensive approach 
can't be said enough.
    Mr. Shays. Thank you. Did you want to say something?
    Dr. Green. Yes.That last statement I completely agree with.
    Mr. Shays. Thank you.
    Ms. Lee.
    Ms. Lee. Thank you, Mr. Chairman. I'm not sure who to 
direct this question to, so whoever can answer it, please do.
    Let me ask you this; with regard to the guidance document, 
abstinence or return to abstinence must be the primary message 
that youth receive or for youth in PEPFAR countries, and 
information about consistent and correct condom use is only 
provided to youth who are identified as those who engage in 
risky behavior. But I want to ask you just from a practical 
point of view, in a classroom setting, how do you distinguish 
between youth who are engaged in risky sexual behaviors and 
those who are not? And doesn't it make sense to provide again 
age-appropriate, scientifically medically sound information 
that includes all aspects of ABC without stigmatizing or 
segmenting part of that message? And so how is that addressed 
at this point? Dr. Gayle or Dr. Gootnick.
    Dr. Gayle. I would just agree that I think that the ability 
to provide the complete message as appropriate at a given age 
is a--seems to me be more effective than segmenting information 
by age group. I think that most of us would agree that we would 
want to have young people abstain from sex as long as possible 
and that would be desirable. But when you're looking at a 
population of young people, it is difficult to segregate 
information based on whether or not somebody's currently 
abstaining from sex or not. And so having half information, not 
complete information, seems to be a less effective approach 
than looking at what's an age-appropriate way of giving people 
more complete information because somebody who is sexually 
inactive and are abstaining 1 day may become sexually active 
the next day, and we want them to have the information that 
allows them to reduce their risk even if they're not totally 
avoiding risk. So I think the ability to do that in a 
comprehensive way at any age would be desirable.
    Ms. Lee. So how is one supposed to separate out youth who 
are high-risk youth in terms of youth who engage in risky 
sexual behavior being the ones who get the information with 
regard to correct and consistent condom use versus those who 
are not identified?
    Dr. Gayle. I think that raises a good point. I think it's 
difficult. I think it is easier for a group of youth who are at 
risk and who are currently sexually active to know that. I 
think it's difficult in a situation of youth who are not 
specifically at high risk who are in a classroom setting, who 
are within a civic organization or other settings where there 
is going to be a mix of young people, to be able to segregate 
information accordingly in a practical sense.
    Dr. Nkya. I would like to add on that. You know, for me, 
according to my experience, 20 years of working with AIDS, I 
have come to discover that all young people are at risk. So 
trying to segregate who is to get it is going to bring some 
problems. I think our message here should be that we should 
target all the youth, whether in school or out of school, give 
them the message and correct information. And more probably, 
try to make sure that every child has the right health 
information because the survey which was conducted in Dar es 
Salaam in high schools in Dar es Salaam, in 1988, zero percent 
of the girls were infected with HIV, and then only one boy was 
found to be infected because of transfusion.
    Two years later, the infection went up 10 times, it was 8 
percent. That means that there is a high, you know, sexual 
activity taking place among schoolgirls, especially where 
poverty is a problem.
    So we should target the girls together with the boys, 
although the infection with the boys was not significant, but 
we should target all the children, even as young as, you know, 
in primary one, to tell them that there is AIDS, do you know 
AIDS, and then we start from there. And make it a sustainable 
program, not just a one-time seminar in school and then you 
disappear. So that is my concern there.
    So that is my concern there, a sustainable program from, 
you know, primary 1, up to university if it is possible.
    Ms. Lee. Thank you very much. I hope the powers that be 
heard you, Doctor, because I think you make a lot of sense and 
it makes sense. And, to me, listening to you, I am trying to, 
again, figure out why the guidance documents instruct--you 
know, in PEPFAR countries--instruct organizations to have the 
primary message as being abstinence only, except the youth that 
they think are identified are at risk in terms of risky 
behavior.
    Doctor Gootnick.
    Dr. Gootnick. I would say briefly that the guidance 
document we refer to is used extensively by the program 
officials in the field and it is valued by them. They cite 3 
key issues and key areas where this guidance may be indeed--
although clear if you read it word for word--hard to apply in 
the field; one of which is the case that you mentioned, the 
issue of how to deal with youth of different age. There are 
different messages that can't under PEPFAR's guidance be 
offered to youths less than 14, youths who are older than 14, 
populations who may be at risk or most at risk, and as a 
practical matter it is difficult for them to apply the 
guidance.
    The second area of confusion is permissible activity with 
respect to condom use. There is guidance for different 
populations that allows you to discuss condoms but not promote 
condoms, and that becomes very difficult for the program 
officials to apply in the field.
    And the third area where there is some confusion is in 
high-risk activities or individuals. There is certain programs 
that PEPFAR may implement for high-risk or most-at-risk 
populations, but in a generalized epidemic it is often very 
difficult to determine who indeed is high risk or most at risk, 
because the fairest way to define that is almost anybody who is 
having sex outside of a known mutually monogamous relationship 
with a noninfected partner or someone who is abstinent.
    Dr. Green. If we go by data, the epidemiologic data, we see 
that 7.2 percent of subSaharan Africans, if you average all the 
countries together in subSaharan Africa, about 7 percent of 
Africans are HIV positive, which means 93 percent are not 
positive. You don't agree?
    Mr. Shays. I was shaking my head because I was thinking 7 
percent of a population is such a huge number. It blows me 
away.
    Dr. Green. Yes it is way too high.
    Mr. Shays. I think of kids going to school with no 
teachers, coming home to no parent.
    Dr. Green. I mention that as an antidote to the thinking 
that everyone is a current risk and all African men are 
promiscuous and all African women have no power--African women 
have more power than we foreigners give them credit for.
    I agree with most of the comments I just heard, Dr. Nkya. I 
feel certain that if we had time to sit down and if you just 
interviewed me and Dr. Nkya and try to find points of 
disagreement, there wouldn't be many. And if Africans could 
choose for themselves, without being influenced by what is on 
the donor menu not only from the U.S. Government but from the 
United Nations, AID, and other organizations I think that would 
be ideal.
    I see a lot of of these problems as growing pains. It is as 
if we were putting billions of dollars into reducing lung 
cancer and we for some reason, because it might hurt people's 
feelings, we didn't have don't start smoking or give up smoking 
if you are already smoking or at least smoke fewer cigarettes 
per day.
    And I have never said that condoms were the only message, 
but it was the main message before PEPFAR, and the other 
interventions were and are for all other major donors treating 
STDs, VCT, voluntary counseling and testing, and treating HIV-
infected mothers with nevirapine. And I think it is a great 
step forward that the U.S. Government for whatever reasons, 
maybe it was for, I don't know, ideological reasons--
Congresswoman Lee, you said you were in on the planning of 
PEPFAR so maybe you know, but I don't know what the reasons 
were, but I think it was a genuine positive step forward to 
include primary prevention, avoid the risk altogether if you 
can.
    But here are the other things you can do if that is not 
possible. And I think programs should be integrated and not 
compartmentalized, and if some people in the field are having 
problems because of the way the earmark is written, nobody 
likes earmarks. I come from 2 generations of foreign service 
officers. My father and grandfather always complained about 
congressional earmarks. I sympathize, but I think it has 
brought us forward.
    Mr. Shays. Let me quickly get a quick response. I am 
surprised that other countries aren't doing more. And am I just 
misreading it? I am surprised that other countries aren't doing 
more, and am I misreading what other countries are doing, No. 
1? And I am also told sometimes when the United States really 
steps up to the plate, other countries feel they don't have to.
    And so, one, is the United States stepping up to the plate, 
even if we had this disagreement about where one-third of the 
prevention dollars go? And No. 2, are other countries doing 
what they should do? Maybe, Dr. Gayle, I could just ask you 
that, and Dr. Gootnick.
    Dr. Gayle. Definitely the United States is stepping up to 
the plate, and, as the earlier panel said, we fund anywhere 
from one-third to one-half depending on how the numbers come 
out in terms of funding. I think the difference is that the 
U.S. Government has always had a strong bilateral program where 
other countries have not, and more of the countries put their 
money through the pooled resources, through the global fund. So 
I think there are a variety of different ways of looking at 
funding, and a lot of the other countries also put their money 
either in the global fund or through programs that are not 
specific sectorial programs and are going to much more combined 
funding approach where they put it into a pool that then gets 
used, so it is harder to track it as AIDS funding.
    That being the case, clearly the U.S. Government is the 
largest funder of HIV programs, and the work needs to be done 
to continue to encourage others to increase their resources.
    Mr. Shays. Quickly, what is the close second? Maybe there 
isn't a close second. Who is second?
    Dr. Gayle. England.
    Mr. Shays. There is certainly not a close second. We take a 
lot of hits on a lot of things but sometimes we don't pat 
ourself on the back.
    Dr. Gayle. I think we should pat ourselves on the back. I 
also think we have to remember that we are the largest economy, 
and when you start looking at our contribution per capita, we 
don't have quite as much to be proud of; we still should be 
proud and we still are the largest contributor, but in terms of 
per capita funding, if you look at some of the smaller 
countries per capita, they actually are contributing 
substantial amounts. So I think we need to look at it in a 
variety of different ways.
    Mr. Shays. Fair enough. Dr. Gootnick.
    Dr. Gootnick. Just to put a couple of numbers to those 
comments, and while not the subject of our analysis, roughly 
speaking it is estimated about $8.3 billion was spent on AIDS 
last year, global spending. About $2.5 billion of that was 
national spending, spending by the Governments of Tanzania, the 
so-called recipient nations. And the remainder of that would be 
donor spending. Of that, OGAC was more than half, about $3.2 
billion, with the rest of the two nations combined somewhere in 
the $2.5 to $2.7 billion range.
    Mr. Shays. That would suggest our economy at 25 percent of 
the world's economy, we are doing 50 percent of the 
contributions.
    Dr. Gootnick. Yes. The other way to look at it is to look 
at the percentage, our share of GDP. There is an aspirational 
notion that donor countries would provide .7 percent of their 
GDP for development assistance, humanitarian assistance, 
broadly speaking. Some countries in Europe get closer to that 
and a few reach it. The United States is about at .1 percent of 
GDP.
    Mr. Shays. Let me do this. Is there any closing comment 
that any of you would like to make, something that we should 
have brought up that we didn't, something that needs to be put 
on the record? And we will start with you, Dr. Green.
    Dr. Green. Just to continue the answer to that question, 
but it brings out something that I would like to say, that I am 
not so concerned about the amounts or even the proportions of 
money; rather, that money is well spent. Daniel Lobier, 
formerly of Cambridge University, now with the Global Fund for 
ATM, estimated that between 1986 and 1991 in Uganda, when 
Uganda turned that epidemic around using its own approach 
before we donors really moved in there, it was before the U.S. 
aid, the first bilateral program, Uganda spent about 25 cents 
per person per year for this highly effective program. It was 
the first really effective program in the world.
    So if money is well spent, we--it is less an issue of how 
much and--but the other important point I would like to leave 
the subcommittee with is that there is a perception out there 
that ABC is something to do with the Bush administration, and 
like a faith-based initiative and something to appease the 
religious right. And for that reason the major donors, United 
Nations, AID, WHO, all the major bilateral multilateral donors 
pretty much are very suspicious of it and don't support the A 
and B parts, by and large, and that is what the government 
panel said.
    Mr. Shays. Very interesting. Dr. Gootnick.
    Dr. Gootnick. Just briefly to reiterate what GAO 
recommended in the aftermath of this study was that Congress--
that the Office of Global AIDS Coordinator collect and report 
information on the downstream implications of the spending 
requirement report it to Congress, and that Congress use it in 
its ongoing oversight of the program. And we reiterate that 
recommendation.
    Mr. Shays. Thank you for doing that. Dr. Gayle.
    Dr. Gayle. Yes, three very brief points, I think this panel 
is the first one where all agree that the ABC approach is 
important and should be the cornerstone of behavioral 
prevention. I think where we disagree is how do we get to that 
comprehensive approach.
    And I would just like to somewhat differ with some of the 
comments that before the PEPFAR program there was not a 
commitment to comprehensive programming. Having run USAIDS 
prevention programs from the very early days, CDC's programs, 
that in fact the U.S. Government strategy was behavior change, 
treatment of STDs and condoms before the PEPFAR. So the idea 
that the--only by having that earmark will we make--keep a 
commitment to comprehensive prevention doesn't speak to the 
facts that a comprehensive approach that includes behavior 
change, has been part of the U.S. Government program for the 
last couple of decades.
    Second, I think that the issues that have been raised that 
there needs to be greater flexibility to integrate programs 
that focus on the other dimensions, the vulnerability that 
people face, the poverty, gender inequity, food insecurity, 
that the other issues that put people at risk for HIV to begin 
with, particularly women, need to be able to be addressed, 
perhaps not directly through resources from PEPFAR, but a 
greater flexibility and much greater coordination of U.S. 
Government funding, so that in fact there is the ability to 
knit together these other aspects that, after all, if we don't 
attack the context in which people's behaviors occur, we are 
not going to be able to change individual behavior, because it 
is often based on just life survival. And so we have to be 
cognizant of those issues.
    And, third, that the importance of a long-term commitment 
to sustainability, many of the programs that we are involved 
in, the aspects that would allow for community buy-in and long-
term sustainability are not allowed, and that we have to 
recognize that if we are going to commit to these programs 
being sustainable in the future, we have to look at how we do 
that and how do we make sure that there is community buy-in, 
there is capacity development, and that these things go hand in 
hand with the immediate need to get programs up and running.
    Mr. Shays. Thank you.
    Dr. Sawere Nkya, you have the last word----
    Dr. Nkya. Mr. Chairman.
    Mr. Shays [continuing]. Before I get the last word.
    Dr. Nkya. I am the last word at home, too.
    Mr. Chairman, I totally agree with what, you know, my 
fellow testimony givers have talked about. But I would like to 
emphasize on flexibility and just bring to attention that, you 
know, empowering women in developing countries is through 
education. If women are not educated we will never, ever be 
able to empower them and they will always remain as vulnerable. 
So probably if there could be some way whereby countries are 
made accountable into promoting women or female education, like 
giving them free education, giving free primary school 
education, because it makes a difference if you are educated or 
not.
    And another thing is that of, you know, trying to remove 
the component of compartmenting people as risky groups or non-
risky groups because that is stigmatizing them. It makes 
people, even if they know they are at risk, they never go for 
anything to help them preserve life, because here we are 
talking about preserving life and as a result also promoting 
the economies of the developing countries through reduction of 
morbidity and mortality.
    So, Mr. Chairman, I request for flexibility and probably a 
change of direction of looking into all countries' needs; 
specifically, you know, to that country, not, you know, the 
comparison with another country.
    Mr. Chairman, thank you very much.
    Mr. Shays. Thank you very much. And we should pay attention 
to you. You came all the way, 6,000 miles, to tell us this, and 
you have been doing this work for decades.
    You are a true hero, a true hero, and we really value your 
testimony. We value the testimony of all our panelists but I 
particularly want to thank you.
    Mrs. Lee, a comment to close.
    Ms. Lee. I want to say, Mr. Chairman, thank you for your 
leadership and for your commitment to address this entire issue 
in a bipartisan way and in a way that makes sense and it works; 
because, as I said earlier, this is about saving lives and it 
is about making sure that people who are living with HIV and 
AIDS can live longer.
    I want to thank all of our panelists. Whether we agree or 
disagree, I think we have to muddle through all of this 
together because it is so serious.
    And the United States must continue to be out front in 
terms of leadership, in terms of resources, and in terms of 
really being committed to allowing countries to do their thing 
in the way that they know how to do it best. And so I hope that 
we can get to that point where we can go back when we do 
reauthorize PEPFAR, look at your testimony, the suggestions you 
have made, and try to figure out how we can incorporate some of 
these very thoughtful suggestions and ideas into what we have 
to come up with in the future. So thank you again, Mr. 
Chairman.
    Mr. Shays. Thank you. I just want to say you are the true 
leader on this. I eat the crumbs off your table. I thank you 
for what you have done, and thank you for participating in this 
hearing and, again, thank both panels, our first and second 
panel, and just to say to Planned Parenthood that enabled me to 
take a really good look at what two countries were doing. I 
went with the expectation I would come back somewhat, frankly, 
disheartened, and I came back with a tremendous amount of 
gratitude for the spirit that I saw in both Tanzania and 
Uganda, particularly among the young people that I met. I 
thought this is an alive place. And I met so many young kids 
who just want to have a better future, that were excited about 
their future, not asking for a lot.
    And it made me feel--and I met a lot of people who are 
running great programs.
    So I came back from my visit to Africa with a feeling that 
it has such unbelievable potential.
    And I just kind of feel that Africa is on the cusp, at 
least in the two countries that I saw, of really turning 
around, not just their concerns with AIDS, but a whole host of 
other issues. So I thank you. And with that, we will adjourn.
    Thank you very much.
    [Whereupon, at 4:22 p.m., the subcommittee was adjourned.]
    [The prepared statement of Hon. Dennis J. Kucinich and 
additional information submitted for the hearing record 
follows:]

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