[Senate Hearing 110-441]
[From the U.S. Government Printing Office]

                                                        S. Hrg. 110-441
                       TUBERCULOSIS, AND MALARIA



                               BEFORE THE

                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION


                           DECEMBER 13, 2007


       Printed for the use of the Committee on Foreign Relations

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                JOSEPH R. BIDEN, Jr., Delaware, Chairman
CHRISTOPHER J. DODD, Connecticut     RICHARD G. LUGAR, Indiana
JOHN F. KERRY, Massachusetts         CHUCK HAGEL, Nebraska
RUSSELL D. FEINGOLD, Wisconsin       NORM COLEMAN, Minnesota
BARBARA BOXER, California            BOB CORKER, Tennessee
BILL NELSON, Florida                 JOHN E. SUNUNU, New Hampshire
BARACK OBAMA, Illinois               GEORGE V. VOINOVICH, Ohio
BENJAMIN L. CARDIN, Maryland         JIM DeMINT, South Carolina
ROBERT P. CASEY, Jr., Pennsylvania   JOHNNY ISAKSON, Georgia
JIM WEBB, Virginia                   DAVID VITTER, Louisiana
                   Antony J. Blinken, Staff Director
            Kenneth A. Myers, Jr., Republican Staff Director



                            C O N T E N T S


Daulaire, Dr. Nils, president and CEO, Global Health Council, 
  Washington, DC.................................................    17
    Prepared statement...........................................    19
Hackett, Ken, president, Catholic Relief Services, Baltimore, MD.    25
    Prepared statement...........................................    27
Kazatchkine, Dr. Michel, executive director, Global Fund to Fight 
  AIDS, Tuberculosis, and Malaria, Geneva, Switzerland...........     6
    Prepared statement...........................................     9
Lugar, Hon. Richard G., U.S. Senator from Indiana................     3
Menendez, Hon. Robert, U.S. Senator from New Jersey..............     1
Smits, Dr. Helen, vice chair, Committee for the Evaluation of 
  PEPFAR Implementation, Institute of Medicine, Washington, DC...    13
    Prepared statement...........................................    15
Sununu, Hon. John E., U.S. Senator from New Hampshire............     5

              Additional Material Submitted for the Record

Prepared statement of Global AIDS Alliance submitted by Dr. Paul 
  Zeitz, executive director, Washington, DC......................    43
Responses from witnesses to questions submitted for the record by 
  Senator Biden:
    Responses of Dr. Michel Kazatchkine..........................    46
    Responses of Dr. Helen Smits.................................    48
    Responses of Dr. Nils Daulaire...............................    49
    Responses of Ken Hackett.....................................    52



                       TUBERCULOSIS, AND MALARIA


                      THURSDAY, DECEMBER 13, 2007

                                       U.S. Senate,
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2:37 p.m., in 
room SD-419, Dirksen Senate Office Building, Hon. Robert 
Menendez, presiding.
    Present: Senators Menendez, Kerry, Feingold, Lugar, and 

                           NEW JERSEY

    Senator Menendez. This hearing will come to order.
    The purpose of today's hearing is to discuss our efforts to 
combat HIV/AIDS, tuberculosis, and malaria. In 2003, Congress 
passed the United States Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Act to authorize funds for the 
President's Emergency Plan for AIDS Relief, known as PEPFAR, 
created the Office of the Global AIDS Coordinator, and 
authorized funds for the Global Fund to Fight AIDS, 
Tuberculosis, and Malaria.
    We are here today to look at the progress and challenges to 
date as we look ahead toward next year's reauthorization of 
this important legislation.
    I want to welcome our distinguished panel of experts, and 
we look forward to a productive discussion.
    The issues that we are here to discuss remain as relevant 
and devastating as ever. Today, 6,800 people around the world 
will become infected with HIV, and 5,700 people will die of 
AIDS-related diseases. This year, more than 1 million people 
will die of malaria, most of whom will be children under 5, and 
tuberculosis will kill 1.6 million people, including 195,000 
who are also infected with HIV/AIDS.
    On May 30, President Bush requested that Congress authorize 
$30 billion to extend the Global HIV/AIDS Initiative an 
additional 5 years. In this call for reauthorization, the 
President emphasized the responsibility to continue to support 
those who have already been reached by PEPFAR, especially the 
continuation of antiretroviral treatment.
    In reacting to the President's proposal, some advocates for 
the fight against AIDS, including a number of Members of 
Congress, while praising progress to date, have called for $50 
billion over 5 years to combat HIV/AIDS, TB, and malaria, 
rather than $30 billion. These resources would represent a 
significant increase over current funding levels.
    The reauthorization of PEPFAR cuts across many of the most 
prominent challenges of foreign assistance. For example, 
regardless of the type of programs we are funding, many of the 
same local factors complicate the intervention. Culture, 
behavior, tradition, faith all play a role.
    In terms of managing and implementing programs, many of the 
same structural challenges exist: Low government capacity, 
abject poverty, absence of government systems, lack of 
accountability, lack of data, and corruption.
    And then, in terms of our strategy and design of programs, 
many of the same dichotomies are also at play. Centralized 
versus decentralized management, bilateral versus multilateral, 
country-driven versus donor-driven, targeted versus diffused, 
and Washington-driven versus field-driven.
    Finally, how do we best monitor and evaluate programs, 
respect intellectual property rights, and incorporate the 
private sector and other partners?
    None of these questions are easy. A few of the responses 
may not be fully satisfying, but we are here today to talk 
about PEPFAR and the Global Fund, and we hope to apply your 
insights to the wider universe also of foreign assistance.
    As the chairman of the Subcommittee of Foreign Assistance, 
I'm interested in the overall management of the PEPFAR program 
in the context of our larger development goals and programs. 
Are we getting the most for our money? Are we doing the right 
mix of programs? How do we balance priorities in education, 
health, economic growth, social investment, and the 
environment? What oversight mechanisms are in place to ensure 
that the funds are being used for the purposes Congress 
intended? If increased resources are authorized, will those 
authorizations and resources--where would they come from, and, 
particularly, how well could they be used?
    It's a unique opportunity today, because we have a chance 
to be both proactive and forward-thinking. While the 
devastation of these issues does not pause, certainly we need 
to be thoughtful and deliberate on how we approach them. Some 
of the best strategic and medical minds are working on these 
issues, so I'm confident we are on the path toward success, but 
this upcoming authorization will establish an important 
framework within which the next 5 years of work will take 
    There is good news and there is bad news. The good news is 
that the global health community has made great strides with 
HIV/AIDS. The bad news is that the questions are now even 
harder. While the U.S.-led effort has made substantial advances 
in providing access to treatment, the need still far outweighs 
the availability of services. The rate at which individuals 
become infected with HIV continues to outpace the rate at which 
they are treated. And, once begun, treatment is a lifelong 
obligation and expense.
    Also, in looking at future costs of these programs, UNAIDS 
estimates that, to achieve universal access to antiretroviral 
medications, the global resource needs for 2010 would be 
approximately $40 billion. This figure does not include costs 
for prevention or care. In the current zero-sum appropriations 
environment, no single intervention is funded in a vacuum; each 
one has an impact on all the others. In this case, I certainly 
reject the idea of a zero-sum budget environment, and I 
believe, as I have said before, that more resources need to be 
provided overall for foreign assistance, and this is a critical 
part of that effort.
    So, the question is: How do we leverage additional 
resources within the government, from other countries, and from 
the private sector to help cover these costs?
    And, last, even with the revised UNAIDS numbers, prevention 
is considered to be of particular importance in the next 5-year 
phase of PEPFAR and other programs. The only way that we are 
going to make inroads against HIV/AIDS is to improve 
prevention, and it cannot just be behavioral interventions that 
we have supported in the past, but we must find new medical 
ways of stopping the disease, whether that is medical male 
circumcision or microbicides or something that we don't yet 
understand. The important thing is that we keep our focus on 
the core issues.
    I also believe that we cannot blind ourselves to the 
possibilities of a wave of new infections that may be coming. I 
believe that people lean toward talking about treatment because 
it's comfortable and measurable, but prevention needs to be a 
priority, moving forward. We can treat, forever; but until we 
learn how to slow the disease, we will not make a lasting 
    So, we look forward to this incredibly important panel and 
what they have to say. We commend you for the work that you 
have all done, individually and collectively. You're making 
great contributions to lifesaving efforts around the world.
    We are going to turn to our other colleagues here, starting 
with the ranking member of the full committee. We are, 
hopefully, not going to be challenged too early by votes on the 
floor, for which there will be several lined up. So, we will 
get through all of the witnesses' testimony, and then we'll see 
where our questioning session begins.
    And, with that, I recognize the distinguished member of the 
full committee, Senator Lugar.


    Senator Lugar. Well, thank you very much, Mr. Chairman.
    As you pointed out, the Foreign Relations Committee is 
meeting again to discuss the reauthorization of the Leadership 
Act Against HIV/AIDS, Tuberculosis, and Malaria. The Leadership 
Act, recognizing that the devastating AIDS crisis required an 
overwhelming response, created the $15 billion President's 
Emergency Plan for AIDS Relief--PEPFAR. This program has 
provided treatment to an estimated 1.1 million men, women, and 
children infected with HIV/AIDS in Africa and elsewhere.
    Before the program began, only 50,000 people in all of sub-
Saharan Africa were receiving lifesaving, but costly, 
antiretroviral drugs. Today, three times that many are being 
treated in Kenya alone. The Leadership Act also focuses on 
prevention programs, with the target of preventing 7 million 
new HIV/AIDS infections.
    As Americans, we should take pride in our Nation's efforts 
to combat these diseases overseas. However, we must act with 
dispatch to build on these efforts, or lives will be lost 
    On October 24, the committee heard testimony from the 
Department of State's Global AIDS Coordinator, Ambassador Mark 
Dybul. He noted that there is increasing concern about United 
States intent with regard to the AIDS programs. While there is 
little doubt that the Leadership Act will eventually be 
reauthorized, the uncertainty with regard to the timing and 
amount of American funding means that fewer new patients will 
receive lifesaving treatment. Partner governments and 
implementing organizations in the field have indicated that, 
without early reauthorization of the Leadership Act, they may 
not expand their programs in 2008 to meet PEPFAR goals.
    At our last hearing, I cited a letter from the Ministers of 
Health of the 12 African focus countries receiving PEPFAR 
assistance. They wrote: ``Without an early and clear signal of 
the continuity of PEPFAR support, we are concerned that 
partners might not move as quickly as possible to fill the 
resource gap that might be created; therefore, services will 
not reach all those who need them. The momentum will be much 
greater in 2008 if we know what to expect after 2008.''
    The committee also received support for early 
reauthorization from AIDS Action, which believes that our 
global partners need to be assured that the U.S. commitment and 
leadership will continue and grow.
    We heard from the Foundation and Donors Interested in 
Catholic Activities, which argues that early reauthorization, 
``will encourage implementing partners to expand the number of 
patients receiving antiretrovirals at the 2008 target levels 
rather than holding back on the new services for fear the 
program's ending or being seriously curtailed. This means many 
more lives will be saved.''
    Part of the original motivation behind the PEPFAR program 
was to use American leadership to leverage other resources in 
the global community and the private sector. According to the 
United Nations, ``every dollar invested by the United States 
leverages two dollars from Europe,'' in the battle against 
AIDS. The continuity of our effort to combat this disease, and 
the impact of our resources on the commitments of the rest of 
the world will be maximized if we act now.
    The Leadership Act is due to expire in September 2008. This 
past August, I introduced Senate bill 1966, which reauthorizes 
the Leadership Act and doubles the funding to $30 billion. If 
the United States signals to the world that it is reaffirming 
its leadership on HIV/AIDS, that will guarantee critical 
continuity in the effort, and will save more lives.
    After consulting extensively with American officials who 
are implementing PEPFAR, I included several modifications in my 
bill which I believe will enjoy broad congressional support. My 
bill clarifies the provision on prevention programs, to make 
more money available for mother-to-child transmission and 
blood-supply safety. It also proposes new benchmarks to 
strengthen accountability and transparency at the Global Fund 
to Fight AIDS, Tuberculosis, and Malaria, which has been a 
critically important partner. I believe we should avoid changes 
that limit programs' flexibility, which has been at the heart 
of success.
    I join the chairman in welcoming our distinguished panel of 
expert implementers who are engaged now in the fight against 
these diseases, and we look forward to their testimony.
    I thank you, Mr. Chairman.
    Senator Menendez. Thank you, Senator Lugar.
    Senator Sununu.


    Senator Sununu. Thank you very much, Mr. Chairman.
    This is an extremely important hearing, and I think both 
Senator Lugar and Senator Menendez have done a great job of 
outlining the scope of the problem, and our--the panelists here 
probably have much deeper experience than any Member of 
Congress in understanding the scope of the crisis we face, its 
impact, not just on health, but on society, across the world, 
on governments, on security, on economic development. All of 
these are tied into the devastation that we've seen brought to 
people around the world as a result of the HIV/AIDS crisis.
    Senator Lugar emphasized, and it is worth emphasizing, the 
importance of American leadership. Our leadership in addressing 
the problem, our leadership in providing funding, our 
leadership in making this a priority here in the United States 
and with all of the developed nations that we know, can provide 
significant assistance, as well. And I think it's important for 
Congress to bear in mind that that leadership will be 
demonstrated, and can be demonstrated in one very specific way, 
and that is by moving a strong and timely reauthorization bill 
for PEPFAR and related programs. Putting forward legislation 
early provides the clarity and the continuity that Senator 
Lugar emphasized. Sometimes in Congress we forget how that's 
received around the world, that other countries, whether they 
are Health Ministers, Foreign Ministers, Presidents, and Prime 
Ministers around the world, watch and see what kind of steps 
the United States is taking in an area as important as this.
    So, moving aggressively with real leadership on PEPFAR 
reauthorization is critical. We have some important issues to 
discuss in that reauthorization, issues like the funding 
levels. The President has proposed a doubling of funds--$30 
billion--but it's important that that's an issue that's 
addressed early so that our counterparts around the world know, 
in a sense, what is expected from them in the way of matching 
support. We need to talk about what obstacles are out there to 
delivering services, and, of course, what the priorities ought 
to be with respect to prevention and treatment, all the while 
keeping in mind that, without flexibility, we're going to make 
problems--we have the potential to make problems worse, and 
have the potential to limit the ability of individuals in 
countries around the world to respond to this crisis.
    We have a real need--and I think, and I hope, our panelists 
will talk about the real need--for developing health care 
capacity in order to deliver prevention and treatment and 
information and support around the world. And ``health care 
capacity'' can mean infrastructure, it can mean workforce, it 
can mean communication, it can mean data collection. But we 
have a lot of work to do to develop systems that can adequately 
address the scope of the HIV/AIDS epidemic, you know, not over 
the next 1 or 2 years, but over the next two or three decades 
that we know it will still be with us.
    This is something that has bipartisan support, and it--that 
makes it, in some ways, very enjoyable to work on. And it's 
something that we've seen experts around the world really focus 
upon and engage in. And the panelists we have here today are no 
exception. I want to welcome all those panelists.
    I certainly want to particularly welcome Dr. Nils Daulaire. 
Dr. Daulaire and I had the opportunity to be together at an 
event that marked World AIDS Day, and talked about a lot of 
these issues. I've seen his presentation before, and I have no 
expectations that he's updated it in the last 10 days or so, 
but it was outstanding when he presented it at Dartmouth, and 
I'm sure it's still outstanding. I welcome him, as a fellow New 
    And I look forward to all of your testimony.
    Thank you, Mr. Chairman.
    Senator Menendez. Thank you, Senator.
    Again, we want to thank all of our distinguished witnesses 
for joining us today: Dr. Michel Kazatchkine, executive 
director of the Global Fund to Fight AIDS, TB, and Malaria; Dr. 
Helen Smits, the vice chair of the committee, of the Institute 
of Medicine; Dr. Nils Daulaire, the president and CEO of the 
Global Health Council; and Mr. Ken Hackett, the president of 
Catholic Relief Services.
    We'll start with all of your opening statements. In the 
interest of time, so there can be a dialog here, we ask you to 
summarize your written statements to around 5 minutes or so. Of 
course, all of your written statements will be included fully 
in the record.
    And, with that, we'll start with Dr. Kazatchkine.


    Dr. Kazatchkine. Thank you, Chairman Menendez.
    Senator Menendez. If you would push your button on.
    Dr. Kazatchkine. Chairman Menendez, Ranking Member Lugar, 
Senator Sununu, I am honored to be here to present an overview 
on the progress that the Global Fund to Fight AIDS, TB, and 
Malaria has achieved so far, the challenges ahead of us, and 
issues that will be important to consider as you renew the 
PEPFAR program. Thank you for your leadership and commitment to 
the fight against the three diseases.
    Through the creation of the Global Fund in 2002, and PEPFAR 
in 2003, as well as a number of other bilateral and 
multilateral programs, world leaders have engaged in health 
interventions in an unprecedented way.
    To date, through the Global Fund, 1.4 million people living 
with HIV in developing countries have been reached with 
antiretroviral therapy. Together with PEPFAR, it is 2.8 million 
people receiving treatment. We are also starting to see results 
of large-scale HIV prevention efforts in a number of countries. 
And, in addition, through Global Fund support, 3.3 million 
people have been treated with anti-TB drugs, and 46 million bed 
nets have been distributed to families at risk of contracting 
    The creation of the Global Fund was inspired by the vision 
to make a difference. In 5 years, the Fund has approved over 10 
billion U.S. dollars for grants in 137 countries all across the 
globe, providing, currently, nearly a quarter of all 
international donor financing for AIDS and two-thirds of all 
international funding for TB and for malaria.
    Since its initial founding pledge in 2001, the United 
States has played a critical role in the Fund's work, providing 
2.5 billion U.S. dollars, nearly one-third of all Global Fund 
financing. Overall,
G-8 countries continue to be the largest contributors to the 
Global Fund, providing 60 percent of all contributions. The 
Global Fund is extremely grateful to the Congress and the 
American people for its support and for their commitment to 
defeating AIDS, TB, and malaria. Be assured, your support to 
the Global Fund is bringing hope and saving lives.
    As you know, the Global Fund approach is based on strong 
founding principles. The one principle underlying every aspect 
of Global Fund financing is country ownership. Within its 
national strategy, each country is responsible for determining 
its own needs and priorities based on consultation with a broad 
range of stakeholders, including government, but also civil 
society. The Global Fund is also committed to performance-based 
funding, meaning that only grant recipients that demonstrate 
measurable and effective results receive resources on an 
ongoing basis.
    The Global Fund has a strong commitment to transparency and 
accountability. This includes working with recipient countries 
to identify key indicators to measure progress. We're presently 
in the process of consolidating a range of activities within a 
comprehensive risk-assessment and management framework that 
will include improving the overall quality of our local funding 
agents, the Global Fund's independent observers on the ground, 
and strengthening our data management systems in order to 
better capture information concerning grants and recipients.
    As part of our commitment to transparency and 
accountability, the Global Fund recognizes the importance of 
having an independent and objective inspector general. The 
Global Fund board recently announced the appointment of a new 
IG and approved the policy to publicly disclose reports issued 
by that office. This policy requires that the inspector general 
post all final reports on the Global Fund's Web site not later 
than 3 working days after they are issued. While restrictions 
can be approved by the board, the presumption is that all the 
inspector general's reports will be made public, and that 
restrictions will be invoked rarely.
    As you renew the PEPFAR program, I ask you to keep in mind 
some key issues. At the Global Fund, resource mobilization and 
sustainability of financing, which Senator Lugar mentioned in 
his remarks, are among our highest priorities. Earlier this 
year, the Global Fund board estimated that the Global Fund 
would have to commit $6 billion, and perhaps up to $8 billion 
annually, to meet country demand for the three disease areas by 
    In September 2007, the Global Fund completed its second 
replenishment cycle in which many donors made long-term pledges 
to the Fund for the period 2008 to 2010. Through this process, 
the Global Fund received strong up-front pledges and other 
estimated contributions, totaling approximately $10 billion for 
the next 3 years. This level of funding will allow the Global 
Fund to renew existing programs and approve new funding rounds 
at existing levels over the next 3 years, but additional 
contributions from existing and new donors are absolutely 
needed if the Fund is to reach its funding targets for 2008-
    We will pursue strong resource mobilization efforts in the 
coming years, including attracting more contributions from the 
private sector and from key emerging economies and other 
innovative ways to generate resources. As the largest 
contributor to the Global Fund, U.S. leadership will be 
critical. As you renew PEPFAR, I hope that the United States 
will achieve its original commitment to provide one-third of 
all contributions to the Global Fund.
    Another priority for me is strengthening the Global Fund as 
a partnership, which is essential, particularly at the country 
level. All constituencies involved in the Fund have crucial 
roles to play in governance, in generating demand, and 
implementing Global Fund-supported programs. The partnership 
includes recipient countries' own commitments, bilateral 
programs, multilateral agencies, such as World Bank, WHO, 
UNAIDS, but also NGOs, faith-based organizations, the private 
sector, and academic institutions. A strong partnership with 
PEPFAR is particularly important for the Global Fund, 
especially at the country level.
    I would like to express, here, my thanks to Ambassador Mike 
Dybul for his dedication and leadership in building an 
excellent relationship between PEPFAR and the Global Fund, and 
I look forward to working even more closely with him in the 
future. In the next phase, we can do more to strengthen 
national strategies and planning processes, and ensure that our 
joint efforts are fully consistent with them.
    AIDS has also highlighted the fragility of health systems 
in many developing countries. As you said, Senator Sununu, it 
has revealed that personnel, equipment, medicines, and 
infrastructures in many countries were never adequate to 
address the basic primary health care needs of the population, 
let alone a new epidemic. Implemented in strategic ways, 
investments to fight AIDS can be the fuel that keeps the entire 
health system's engine going.
    Because of the many potential benefits of disease-specific 
programs, the Global Fund is engaging strongly with the broader 
health systems agenda. In November, the Global Fund board 
approved a new set of principles to guide Global Fund financing 
of health-system strengthening as part of approaches to the 
three diseases. The Global Fund is also the first major donor 
to give in-principle approval to accepting national strategies 
as financing instruments, which will be a major step in 
harmonizing the efforts of all donors as they come together to 
provide finance around a single national health plan, rather 
than multiple plans and strategies.
    Finally, the Global Fund is currently working hard to make 
adjustments to the structures and operations of both its 
secretariat and grantmaking processes so that it is equipped to 
deal with the next phase of growth. In order to preserve our 
hard-won reputation as a lean, flexible, country-owned 
mechanism that provides financing rapidly, reliably, and in a 
sustainable manner, we're currently taking stock and working to 
streamline our processes so that interacting with the Global 
Fund is as simple as possible for countries.
    During the past 5 years, PEPFAR and the Global Fund, 
together, have shown that significant impacts can be made 
against the major diseases of poverty. The world needs 5 more 
years of PEPFAR, and it needs the U.S. leadership and 
generosity in the field of global health. A well-funded Global 
Fund, along with PEPFAR, ensures that health benefits extend 
beyond the 15 PEPFAR focus countries, including communities 
affected by TB and malaria.
    Mr. Chairman, distinguished Senators, AIDS, TB, and malaria 
continue to take a terrible toll on millions of people around 
the world. I ask for your ongoing concerted attention to 
fighting these diseases through the critical support of the 
U.S. Congress for PEPFAR and the Global Fund. Tackling these 
major diseases of poverty remains the most pressing public 
health challenge of our time.
    Thank you very much.
    [The prepared statement of Dr. Kazatchkine follows:]

 Prepared Statement of Dr. Michel Kazatchkine, Executive Director, The 
     Global Fund to Fight AIDS, TB and Malaria, Geneva Switzerland

    Chairman Menendez and Ranking Member Lugar, and distinguished 
members of the Senate Foreign Relations Committee, I am honored to be 
here to present an overview on the progress the Global Fund has made so 
far, the challenges ahead of us and the issues that will be important 
to consider as you renew the PEPFAR program. As a physician who has 
treated people living with AIDS for over 20 years, I have seen first-
hand the dramatic gains we have made in the fight against AIDS, TB, and 
malaria. Your work to reauthorize the AIDS program will undoubtedly 
help to leverage other donors to do more as well.
    At the beginning of this decade a revolution was set in motion. The 
world used to think that health came as a consequence of development; 
but the AIDS crisis has shown us the reverse--that if you do not 
address health, other development efforts will falter. Within this new 
paradigm, it has become apparent that health needs to be looked at as a 
long-term investment that is essential to achieving development. 
Through the creation of the Global Fund in 2002 and the PEPFAR program 
in 2003, as well as a number of other bilateral and multilateral 
programs, world leaders have begun to engage in health in an 
unprecedented way by devoting attention and resources to fighting the 
diseases that take the greatest toll on the poor: AIDS, tuberculosis, 
and malaria.
    As a result of this unprecedented effort, in just 6 years we are 
seeing dramatic change in the landscape of the countries where we work 
as more people have access to treatment and lives are being saved. In 
concert with what the PEPFAR program has achieved in its 1.5 focus 
countries, the Global Fund is translating the hope of access to 
prevention, treatment, and care into reality around the world. As we 
recently reported, results from Global Fund-supported programs show 
that millions of people are receiving essential health services and 
that coverage is at least doubling each year. To date, through the 
Global Fund, 1.4 million people living with HIV have been reached with 
life-saving antiretroviral (ARV) therapy and together with PEPFAR, 2.8 
million people have received treatment. In addition to its focus on 
HIV/AIDS, the Global Fund has become the largest international financer 
for TB and malaria programs by far, providing two-thirds of all donor-
funding for these two diseases. To date, 3.3 million people have been 
treated with anti-TB drugs and 46 million bed nets have been 
distributed to families at risk of contracting malaria.
    These 2007 figures emphasize a strong and steady increase in the 
number of people treated for AIDS and TB, and a spectacular growth in 
coverage of malaria interventions. Those who have regained their health 
are able to care for their children, return to work and lead 
meaningful, productive lives. In Ethiopia, for example, as a result of 
comprehensive HIV prevention and treatment programs, HIV prevalence has 
declined from 8.6 percent to 5.6 percent among women who visit 
antenatal clinics. A multicountry malaria grant in Southern Africa has 
contributed to an 87-96 percent decline in malaria incidence. 
Eventually, societies most affected by declines in human capital 
resulting from illness and death will be able to translate these gains 
into growth and opportunity. Building on what we have achieved, it is 
realistic to think that we can have an even more significant impact on 
AIDS, TB, and malaria in the future.
        the global fund to fight aids, tuberculosis and malaria
    The creation of the Global Fund to Fight AIDS, Tuberculosis and 
Malaria was inspired by the vision to ``make a difference.'' Simply 
put, the Global Fund is investing the world's money to save lives. This 
is a huge responsibility, and one that inspires me every day as the 
Global Fund's executive director. This vision has also allowed the 
Global Fund to come a long way in a very short period of time. Since 
2002, the Global Fund has now approved over $10 billion for grants in 
137 countries around the world, supplying nearly a quarter of donor 
financing for AIDS and providing two-thirds of donor funding for both 
TB and malaria.
    Since its initial founding pledge in 2001, the U.S. has played a 
critical role in the Global Fund's dramatic scale-up, providing $2.5 
billion in just 6 years, nearly one-third of all Global Fund financing. 
In total, G-8 countries continue to be the largest contributors to the 
Global Fund, providing 60 percent of all contributions. Other countries 
are doing their part. The Global Fund is grateful to Congress and the 
American people for its support and for their commitment to defeating 
AIDS, TB, and malaria.
    With this massive amount of resources, the Global Fund has achieved 
significant impact. In mid-June, we estimated that 1.8 million lives 
had been saved through Global Fund supported programs, with an 
estimated 100,000 additional lives saved every month. In addition, the 
Global Fund is now disbursing more funds to more grants faster than 
ever before. More than half of the total amount disbursed (53 percent) 
has been to sub-Saharan Africa, with the remainder disbursed to East 
Asia and the Pacific, Latin America and the Caribbean and Eastern 
Europe and Central Asia, roughly equal at 10-14 percent. The Middle 
East/North Africa and South West Asia have received 5 percent and 6 
percent respectively of the total amount disbursed.
    The Global Fund supports integrated prevention and treatment 
strategies in the three disease areas. Although the portfolio has so 
far favored treatment, the proportion of spending for prevention is 
significant. For example, in 2006, one-third of the $926 million 
budgeted for HIV grants were allocated for prevention. Drugs and 
commodities account for nearly half of Global Fund spending, while 
broad health systems strengthening leveraged through disease programs, 
including human resources, management capacity-building, monitoring and 
evaluation and infrastructure/equipment represents between one-third 
and half of spending. This is consistent with the objectives of the 
Paris Declaration on aid effectiveness and highlights how AIDS, TB, and 
malaria funding can have a positive effect on health systems. The 
Global Fund has been among the first to transparently measure and 
report against the Paris indicators.
    As well as supporting programs in 137 countries around the world, 
the Global Fund is also an integral partner with PEPFAR in its 15 focus 
countries. A strong partnership with PEPFAR is particularly important 
for the Global Fund, especially at the country level, where it provides 
additional leverage to PEPFAR resources, including addressing TB, which 
is a major cause of death for people living with HIV. The Global Fund 
provides a vehicle by which U.S. resources can be harmonized and 
leveraged with other major international donors, as well as civil 
society and private sector implementers, in the fight against AIDS, TB, 
and malaria.
    Since I came on board as the Global Fund's Executive Director, I 
have been working closely with Ambassador Dybul to ensure that the U.S. 
bilateral program and the Global Fund are working effectively and 
efficiently together. We are seeing many examples of this coordination 
in the field. In Rwanda, Ethiopia, Cote d'Ivoire and Haiti, we are 
seeing increasingly strong collaboration and synergy, and I have made a 
number of joint country visits with Ambassador Dybul this year. In many 
other countries, coordination and information sharing are excellent. We 
are also working together on reporting results, to avoid duplication of 
efforts and ``double counting.''

                    global fund founding principles

    Based on strong founding principles, the Global Fund has 
experienced dramatic growth in a short period of time. At its core, the 
Global Fund was created to provide a new channel for significant 
additional resources for the fight against AIDS, TB, and malaria by 
investing the world's money to make a difference and to save lives. The 
Fund has been, and remains, primarily a financing instrument. As a 
result, for the Global Fund to continue its scale-up, multilateral and 
bilateral programs, including USAID, civil society, the private sector 
and others need to come together to assist in the development of 
country-driven funding proposals and to support the implementation of 
    The guiding principle underlying every aspect of Global Fund 
financing is the concept of country ownership. Within its national 
strategy, each country is responsible for determining its own needs and 
priorities, based on consultation with a broad group of stakeholders 
that includes not only government, but other bilateral and multilateral 
organizations, civil society, faith-based organizations, the private 
sector and people living with or affected by the diseases. Global Fund 
grants are country-owned, but that does not mean they are always 
government-led. In fact, NGOs, faith-based organizations and the 
private sector are implementing about 40 percent of Global Fund grants. 
This multi-stakeholder approach is key to ensuring that resources reach 
programs for men, women and children who are suffering from and are at 
risk of AIDS, TB, and malaria.
    The Global Fund is also committed to performance-based funding, 
meaning that only grant recipients who can demonstrate measurable and 
effective results will be able to receive additional resources. In 
other words, initial funding is awarded solely on the basis of 
technical quality of applications, but continued and renewed funding is 
dependent on proven results and achieved targets. In order to measure 
performance, the Global Fund has put in place a rigorous measurement 
and evaluation system that reviews program goals and objectives put in 
place by each of the recipient countries. This begins at the time the 
grant agreement is signed, when targets and indicators are agreed upon 
based on objectives outlined by the countries. Results are tracked at 
every point in the process, from disbursement requests to performance 
updates, and requests for continued funding at the 2-year point of the 
    The Global Fund also has a strong commitment to transparency and 
accountability. This is illustrated by the broad range of information 
available on our Web site. All approved proposals, signed grant 
agreements and grant performance reports are available for review in 
unedited form, as are documents discussed at board meetings. The public 
is also able to track the progress of local programs by reviewing 
grantee reports. Additional efforts are underway to enhance available 
information concerning the performance and impact of grants.
    As part of its commitment to transparency and accountability, the 
Global Fund recognizes the significant role and importance of an 
independent and objective Office of the Inspector General (OIG). The 
OIG reports directly to the Global Fund Board, not to the Secretariat, 
ensuring the integrity and effectiveness of Global Fund programs and 
operations. At its recent meeting in November the Global Fund Board 
announced the appointment of a new inspector general, and approved a 
policy for publicly disclosing reports issued by the OIG.
    This new policy requires that the Inspector General post all final 
reports on the Global Fund's Web site no later than 3 working days 
after they are issued. In the case of some reports, the IG has the 
discretion to recommend, based on limited exceptions listed in the 
disclosure policy, that restrictions on publication be applied. Such 
exceptions are intended to allow for ``exceptional circumstances where 
legal or practical constraints would limit the Global Fund's ability to 
achieve full transparency if it is to protect the interests of the 
Global Fund and its stakeholders or legitimate interests of those who 
deal with the Global Fund.'' \1\ The restrictions would require the 
approval of the Global Fund's Board, following advice from the 
organization's legal counsel and review by its Finance and Audit 
Committee. It is important to emphasize that while restrictions can be 
approved by the board, the presumption is that reports would be made 
public and this restriction would be invoked rarely.
    \1\ Policy for Disclosure of Reports Issued by the Inspector 
General, GF/B16/8, Annex 3.
    The Global Fund is also pioneering practical systems that balance 
the demand for accountability with the need for efficiency. This 
includes working with recipient countries to identify key indicators to 
measure progress, and ensuring that where possible, Global Fund 
reporting requirements rely on existing processes. The use of Local 
Fund Agents (LFA) is another accountability mechanism designed to 
provide appropriate oversight while respecting local implementation. 
LFAs are independent organizations that act as the Global Fund's eyes 
and ears on the ground, and play an important role in assessing the 
financial management systems and capacity of grant applicants, the 
performance of grants and the reporting of results.
    The Global Fund is currently bringing together various risk 
management and oversight functions into a comprehensive risk assessment 
and management framework. It has also recently undertaken a process of 
retendering its LFA contracts to improve overall quality of these 
agents. The new LFA statement of work will contain more explicit 
requirements on the monitoring of Principal Recipients and 
    Finally, the Global Fund is working on improving its data 
management systems in order to better capture information concerning 
grant subrecipients. Starting in January 2008, the Fund will begin 
implementation of the Enhanced Financial Reporting system which will 
entail requesting a minimum set of budget and expenditure information 
from Principal Recipients on a yearly basis, including cost category, 
program activity, and implementing entity. As part of an integrated 
information system, by January 2009, the Fund will have collected a 
full set of data on all grants and will be able to provide a very 
comprehensive analysis of the portfolio.

                challenges and priorities for the future

Resource Mobilization and Sustainability
    Resource mobilization and sustainability are among our highest 
priorities. Our commitment to treating millions of people with life-
long ARV treatment means that long-term sustainability is a key issue 
for the future. We must not relent in building on our success. Slowing 
down would present an enormous risk in reversing the significant gains 
we have made in fighting AIDS, TB, and malaria.
    Earlier this year, the Board estimated that the. Global Fund would 
have to commit $6 billion, and perhaps up to $8 billion annually, to 
help meet country demand by 2010 for prevention, treatment, and care in 
the three disease areas. At least tripling in size over the next 3 
years will require significant effort on numerous fronts. The Global 
Fund is now receiving increasing support and trust from major donors, 
predominantly the G-8 countries, and solid progress has also been made 
in private sector engagement through Product (RED) and the development 
of new sources of funding, such as the Debt2Health initiative.
    In September 2007 the Global Fund engaged in its Second 
Replenishment cycle which was a process to acquire long-term pledges 
for 2008-2010. At the Replenishment Meeting held in Berlin, the Global 
Fund received strong upfront pledges of $6.3 billion. Additional 
minimum contributions are anticipated at $3.4 billion, resulting in an 
approximate total of $10 billion for the next 3 years. These 
commitments ensure that we will have the resources we need to approve 
the continuation of all ongoing programs over the next 3 years--
estimated at a total of $6.5 billion--and will also be in a position to 
support new programs valued at $3.2 billion. It is important to 
emphasize that this level of funding will essentially be more complex. 
In order to preserve our hard-won reputation as a lean, flexible, 
country-owned mechanism that provides financing rapidly, reliably and 
in a sustainable manner, we are currently taking stock and working to 
streamline our processes so that interacting with the Global Fund is as 
simple as possible for countries.
    In order to focus on its mission to rapidly disburse resources, at 
its founding the Global Fund contracted with the World Health 
Organization to provide administrative services and human resources 
support. Having now matured as an organization, the Global Fund Board 
decided in November 2007 that the agreement with WHO will terminate at 
the end of 2008. As we evolve to become an independent foundation with 
its own systems and human resource policies, I am confident that the 
Global Fund Secretariat will become one of the most modern, dynamic and 
attractive workplaces in the field of global health.


    During the past 5 years, PEPFAR and the Global Fund together have 
shown that significant impacts can be made against the major diseases 
of poverty. The world needs 5 more years of PEPFAR and it needs U.S. 
leadership and generosity in the field of global health.
    The U.S. also needs a strong and well-funded Global Fund to 
compliment its work, ensuring that health benefits extend beyond the 15 
PEPFAR focus countries, helping to harmonize U.S. support with that of 
other major donors and linking AIDS programs to those of the other 
major infectious diseases.
    The progress that has been achieved to date in the field of global 
health is the result of both our efforts. PEPFAR and the Global Fund 
are showing that well-implemented bilateral and multilateral efforts 
can be mutually reinforcing, and that health and socio-economic 
development and stability are intertwined. They are showing that health 
programs can be a force--not only for development--but for 
international stability and security.
    We recognize that AIDS, tuberculosis, and malaria continue to take 
a terrible toll on millions of people around the world. Continuing the 
fight against these diseases remains the most pressing public health 
challenge of our time.
    Thank you again for the opportunity to testify. I look forward to 
answering your questions.

    Senator Menendez. Thank you.
    Dr. Smits.

                         WASHINGTON, DC

    Dr. Smits. Good afternoon, Mr. Chairman and members of the 
committee. I'm Dr. Helen Smits, and I was honored to serve as 
the vice chair of the Institute of Medicine Committee that 
evaluated the early implementation of PEPFAR.
    As you know, you mandated this study in the original 
Leadership Act. It was executed under contract with the 
Department of State and carried out by an interdisciplinary 
committee of experts from many nations who visited the PEPFAR 
focus countries to talk with people, funding and implementing 
    I'd like to thank my fellow committee members and the IOM 
staff for all their hard work, as well as all the people in the 
focus countries and in OGAC who spent so much time with us.
    The opportunity to visit focus countries in this context 
was very moving to me. I met an amazingly diverse group of 
people--individuals living with HIV, doctors, nurses, 
traditional healers, government ministers--and they gave one 
very consistent message; that was, ``Thank you.'' It was very 
moving, at times. They sang for me, they danced, you know, they 
served me homemade cakes. At one point, I was given a gift of 
two live birds. They thanked me, as a representative of the 
American people, even though I was an evaluator, but I want to 
convey to you how heartfelt the appreciation is for the program 
you have funded--conceived and funded.
    As my written statement, I've submitted a copy of the 
actual summary of the IOM report, and--with all of the 
committee's recommendations. I'll summarize them very briefly, 
and then focus a little bit more on the one recommendation 
applicable to Congress, which is that you remove all budget 
    We saw that the U.S. Global AIDS Initiative has made a very 
strong start, and our recommendations are intended to 
strengthen a good program, not to criticize the program.
    The recommendations involve placing even greater emphasis 
on prevention. We're all agreed you can't treat your way out of 
this epidemic. We need to use a variety of strategies that are 
targeted to the local problem, and we need to be very careful 
to understand how well those strategies are working. We must 
continue to pay a great deal of attention to the vulnerability 
of women and girls, with emphasis on the legal, economic, 
social, and educational factors that make them so vulnerable. 
I'm sure you've all seen the charts that show that the disease 
rate of HIV infection rises very rapidly in young women in the 
late teen years in all of these countries, and it's very 
important to tackle that problem.
    We have to strengthen and enhance our commitment to 
harmonization. The committee particularly suggested that an 
important step toward harmonization would be for us to work 
toward use of the WHO prequalification process as the single 
standard for approving generic medications. If there are 
problems with that process, we should specify what they are, 
and we should use our expertise to help the WHO change them.
    We also thought that all services--prevention, treatment, 
and care--can be better integrated, and that the resulting 
synergies will improve all of the programs.
    As we continue to strengthen country capacity, we need to 
support the expansion of local human resources. It doesn't help 
to shift tasks from doctors to nurses if there aren't enough 
nurses. Expanding nursing schools and schools for clinical 
officers, appears very practical and something that we should 
be able to support.
    And we need to know what works. We need to keep focusing on 
learning and reporting what have been the effective strategies 
so that the various participants in this program and the 
individuals implementing other programs, can learn from one 
    In order to support these improvements, we recommend that 
Congress eliminate all budget allocations, but shift to a focus 
on setting priorities and holding PEPFAR accountable. I want to 
make clear, we're not suggesting you decrease accountability; 
in fact, we think accountability for results will be better 
than simply accountability for how you spend the money.
    We saw some very impressive staff out there in the field, 
working very hard. If Congress can specify the results it would 
like to see, we're sure that they can figure out how to get 
those results.
    Let me just run very quickly through some specific reasons 
why we want allocations eliminated.
    First of all, conditions vary greatly in the different 
countries. The challenge of reaching the rural poor in 
Mozambique and Tanzania across very bad roads is very different 
from the challenge of reaching urban patients in Nairobi. We 
didn't study the relative costs, but we assume that the cost of 
treatment where you have very serious travel problems, is going 
to be higher.
    Second, the epidemic varies greatly in different countries. 
The strategy for Vietnam, where it's an injecting-drug-user 
epidemic, is very different from the strategy to be used in 
South Africa, where it's primarily an epidemic of heterosexual 
    Interestingly enough, situations change very rapidly, and 
sometimes very much for the better, and the program needs to 
respond. Budget allocations can limit flexibility. We're in a 
new phase of prevention where male circumcision will become 
very important. It's a relatively expensive intervention, but 
it's a one-time intervention, where you have demand among adult 
men. If, at the same time, you begin circumcising newborn boys, 
eventually the need to provide that service will go--will 
greatly decrease.
    Changes in drug prices, changes in the climate can make 
costs change. In Mozambique every few years, the north of the 
country is cut off from the south of the country, and you need 
to have the flexibility to have the money to help the country 
get its drugs out to the north so that people's treatment is 
not interrupted.
    We saw the rigid separation among treatment, prevention, 
and care that results from the budget allocations as being very 
difficult. Predictions, for example--and I could give you many 
arguments about this--but the predictions are that many of the 
new cases in the next year, particularly in the countries with 
the greatest success to date in changing overall behavior, the 
new cases will come from faithful, discordant couples, where 
one is positive and one is not. And, unfortunately, the 
fidelity message may mislead them into thinking they're safe. 
We need to focus on identifying them at the point of treatment 
or care, testing them and giving them very sophisticated 
message about how prevention applies to them.
    In closing, I'd just like to say that in 2003 this Congress 
set the standard for international leadership in the fight 
against AIDS, and I'm certainly very proud, as an American, to 
see that you did that. You now have the opportunity to take the 
response to the next level and to leave a truly lasting legacy 
of American leadership. I hope you will seize this opportunity, 
and I hope, also, that you'll visit, for yourselves, and get 
some of those thank yous.
    Thank you for the opportunity to testify. I'd be happy to 
address any questions you may have.
    [The prepared statement of Dr. Smits follows:]

Prepared Statement of Helen L. Smits, M.D., MACP, Vice Chair, Committee 
      on the President's Emergency Plan for AIDS Relief, (PEPFAR) 
    Implementation Evaluation, Board on Global Health, Institute of 
            Medicine, The National Academies, Washington, DC

    Good morning, Mr. Chairman and members of the committee. I am Dr. 
Helen Smits, and it was my privilege to serve as the vice chair of the 
Institute of Medicine committee that evaluated the implementation of 
PEPFAR. As you know, this study was mandated by the Leadership Act and 
executed under a contract with the Department of State. It was carried 
out by an interdisciplinary committee of experts from many nations who 
visited the PEPFAR focus countries to talk with people funding and 
implementing programs. I would like to thank my fellow committee 
members and the IOM staff for their hard work as well as all of the 
people in the focus countries and at OGAC who spent so much time 
meeting with us.
    The opportunity to visit focus countries was a very moving one. I 
met as diverse a group of people as you could imagine: Doctors and 
nurses, groups of people living with HIV, village councils and the 
orphans they cared for, missionaries and traditional healers, heads of 
government ministries, representatives of our partner countries, as 
well as the dedicated American staff members who make PEPFAR work. 
There was one consistent message: ``Thank you.'' I was sung to; I 
attended special dance performances; I was served tea and homemade 
treats; I was even at one point given a gift of a pair of live birds. 
All of these people thanked me as a representative of the American 
people; I want to convey those thanks to you for conceiving and funding 
this program.
    I have submitted as my written statement a copy of the Summary of 
the IOM committee's report with all of the committee's recommendations. 
I will summarize them briefly and spend a bit more time on the one 
recommendation that is directed to Congress--namely, to eliminate the 
budget allocations.
    The U.S. Global AIDS Initiative has made a strong start and is 
progressing toward its 5-year targets. The challenge now is to maintain 
the urgency and intensity that have led to early success while placing 
greater emphasis on long-term strategic planning for an integrated 
program in which prevention, treatment, and care are much more closely 
linked, and on capacity-building for sustainability.
    The committee recommendations to the Global Aids Coordinator, many 
of which are already in the process of implementation, are as follows:

   Even greater emphasis on prevention is needed. This must be 
        based on a greater understanding of exactly where the latest 
        cases have occurred.
   There should be increased attention to the vulnerability of 
        women and girls with emphasis on the legal, economic, social, 
        and educational factors that lead to spread of the disease.
   We must continue and strengthen our commitment to 
        harmonization--with the host countries and with other donors. 
        In particular, we should work with the World Health 
        Organization to accept their prequalification process as the 
        single standard for assuring the quality of generic 
   All services--prevention, treatment, and care--must be 
        better integrated. The resulting synergies will improve 
        programs in all areas.
   As we continue to strengthen country capacity to fight the 
        local epidemic, we should support expansion of local human 
        resources. Many of these countries have too few nurses and 
        clinical officers. Helping to train new ones will be more 
        productive that only retraining the ones who exist.
   We need to know what works. A focus on learning from 
        experience will only strengthen the program.

    In order to support all of these improvements, we recommend that 
Congress shift from a budget allocation approach to one of setting 
priorities and holding PEPFAR accountable--from a focus on how the 
money should be spent to a focus on what the money is accomplishing. 
Allocations have unfortunately made spending money in a particular way 
an end in and of itself rather than a means to an end. They have 
reduced the program's ability to adapt to local conditions and to 
respond effectively to changes either in the epidemic or in our 
constantly growing knowledge of how to fight it.
    In eliminating budget allocations, Congress should retain the 
results-oriented nature of the program. Let me be clear that the IOM 
committee is not suggesting the diminishment of accountability. 
Instead, we are recommending an approach that we believe will result in 
more meaningful targets and greater accountability. Congress should 
hold the Global AIDS Coordinator accountable for demonstrating that we 
are actually succeeding against the pandemic, not simply succeeding in 
spending money on it. If Congress can specify the results it would like 
to see, program staff can figure out how to get those results. The 
increase in flexibility that will result from the elimination of budget 
allocations will make us a better partner with the host countries and 
with other donors.
    PEPFAR is not a single, uniform program the details of which can be 
specified by the Global AIDS Coordinator or Congress. In the focus 
countries PEPFAR is 15 distinct programs reflecting the unique 
circumstances and epidemics of each. I realize that this is nothing new 
for Congress--you contend with the uniqueness of 50 States everyday. 
But if you magnify many fold the variation that you see between 
Delaware, Indiana, Florida, and Alaska, you will begin to get a sense 
of the challenge of trying to apply a single approach across countries 
as different from one another as Guyana, South Africa, Mozambique, and 
    The specific reasons for eliminating allocations are as follows:

   Conditions vary greatly in the different countries. The 
        challenge of treating the rural poor in Mozambique and Tanzania 
        is very different from that of treating urban residents in the 
        slums of Nairobi.
   The epidemic varies greatly in different countries. The 
        strategies for reaching patients with treatment and for 
        prevention are very different in Viet Nam, where the epidemic 
        is driven by injecting drug users, from those in South Africa, 
        where the spread is heterosexual.
   Situations change rapidly and the program needs to respond; 
        budget allocations can limit crucial flexibility. We are in a 
        new phase of prevention with adult male circumcision added to 
        the armamentarium of effective strategies--and altering the 
        cost of prevention. Changes in drug prices, availability of 
        specific medications, approaches to testing, or even climate 
        can have the same effect. Floods in Mozambique frequently cut 
        the northern section of the country off from the south; means 
        must be found to continue the regular delivery of medications 
        when that happens.
   The rigid separation among treatment, prevention, and care 
        that results from allocations should be ended. Predictions are 
        that many of the new infections in affected countries over the 
        next years will come from discordant couples where one partner 
        is positive and one is not. Ensuring that treatment and care 
        both carry a strong prevention message can make a real 
        difference in our ability to reach the people we wish to 

    In closing, in 2003 Congress set the standard for international 
leadership in the fight against AIDS. You now have the opportunity to 
take the United States response to the global AIDS epidemic to the next 
level and leave a truly lasting legacy of American leadership.
    I hope you will seize this opportunity. I also hope you will visit 
for yourselves to see the remarkable accomplishments of the program to 
date--and to receive in person the gratitude of those who benefit.

[Editor's note.--The Summary of the IOM committee's report and 
additional material mentioned above was too voluminous to include in 
this hearing. It will be maintained in the Foreign Relations 
Committee's permanent record. It can also be viewed at: http://

    Senator Menendez. Thank you. Thank you, Dr. Smits. What did 
you do with the two live birds?
    Dr. Smits. Oh----
    Dr. Smits [continuing]. I didn't think I'd do very well in 
Customs with them. We gave them----
    Dr. Smits [continuing]. To the nice young woman from the 
NGO who had taken us to visit the village.
    Senator Menendez. Dr. Daulaire.


    Dr. Daulaire. Thank you, Mr. Chairman, for your approach to 
looking at PEPFAR in the broader context of U.S. foreign 
assistance; you, Ranking Member Lugar, for starting this 
process for reauthorization of PEPFAR; Senator Kerry, for your 
work as cochair of the CSIS Task Force on HIV/AIDS over the 
past several years; and my neighbor and colleague, Senator 
Sununu, with whom I had the pleasure of spending a snowy Sunday 
in his home State of New Hampshire just a couple of weeks ago.
    I request that my written statement be entered into the 
record, and I will keep this short so that we will have time 
for some dialog.
    But let me say, in summary of my written statement, the 
Leadership Act has been both historic and constructive. And the 
Global Health Council and our membership, both here in the 
United States and around the world, endorse its speedy and 
thoughtful reauthorization.
    The Global Health Council is a worldwide membership 
alliance representing over 480 organizations around the world 
and over 5,000 health professionals. Our members are on the 
front lines of global health. They're the ones who are dealing 
with these issues, face to face. And, personally, I'm a 
physician and a public-health scientist, so I'm speaking to 
this issue from that standpoint.
    Now, evidence is at the heart of everything that we try to 
do, and the evidence is this: PEPFAR and the Global Fund have 
begun to show substantial impact, in terms of reducing the toll 
of HIV/AIDS, reducing mortality, and we are beginning to show 
signs of reducing new incidents, as recent UNAIDS statistics 
have shown. So, in a sense, what we've had over the past 4 
years, with the emergency plan is the public-health equivalent 
of an emergency room in full swing. But now it's time, under 
reauthorization, to start looking at this issue from the 
standpoint of managing the community health center. Someday 
we'd like to be able to close the emergency room and deal with 
this in the communities themselves, through prevention and 
early care, rather than having, as we've had to do, to mount an 
emergency campaign of this sort. But we must recognize that 
AIDS will be with us, no matter what the scenario, for a very, 
very long time; and so, we need to start thinking about AIDS 
like other chronic diseases.
    The evidence in dealing with all chronic diseases, and the 
mounting evidence about HIV/AIDS globally at this point, is 
that thoughtful integration of treatment, care, and prevention 
can, and does, lead not only to better outcomes, but to fewer 
infections. And that certainly is an area that needs attention. 
As my colleague has just said, it's critical that PEPFAR-2, the 
next iteration, scale up prevention using the growing body of 
information and evidence that we have about the varying 
characteristics of how HIV is spread. It's also very clear, as 
we just heard, that one size does not fit all, and that there 
has to be more flexibility built into the future authorization, 
whether that's a softening of earmarks or their elimination 
    Our members tell us that allowing decisions on prevention 
to be made by those who are actually dealing with it on a daily 
basis, dealing with the microaspects of this epidemic, has far 
better impact than having a one-size-fits-all determination 
coming out of Washington. And the facts on the ground do call 
for greater flexibility.
    And, second, another provision in the existing law that has 
been deeply counterproductive, from the standpoint of our 
members who are on the front lines implementing, is the APP, 
the so-called ``antiprostitution provision,'' which has made it 
more difficult, even though that was not its intent, for many 
of our members to engage constructively in dialog with 
prostitutes and commercial sex workers, and to really have an 
impact. That should be stricken from the new act.
    We've been talking about AIDS this morning, but obviously 
it's an AIDS, TB, and malaria act, and the next point I'd like 
to make is the importance of integration across a wider range 
of issues.
    First, it is critical to address TB and malaria, but, 
fundamentally, we must recognize the importance of 
strengthening health systems, especially human infrastructure, 
and to work much more closely with other health efforts. This 
is fundamentally important because if you've got a sick mother 
and an unhealthy child, whether they have HIV or not, they 
deserve attention. We have the same systems, the same health 
care workers, the same clinics that deal with them. And it's 
notable that, with the remarkable technical success of dealing 
with neonatal AIDS with the use of nevirapine, we've still had 
very little impact, because many women don't come to the HIV/
AIDS clinics, because adequate maternal and child health 
services and family planning services aren't available there; 
their children don't come in because they don't have good basic 
child health care services. All of these services are 
critically important and need to be strengthened together.
    Finally, it's important that PEPFAR move increasingly 
toward becoming a learning organization. Operations research, 
which is very different from the kind of clinical and 
scientific research carried out by the NIH, is vital to 
improving programs, to refining them; and sometimes it seems 
that there's been a little bit of a barrier between the 
operations research and the implementation side. Learning from 
operations research needs to be encouraged. We would not have 
eliminated smallpox around the world without on-the-ground 
operations research. And few of us would be using Apple 
computers and iPods and iPhones if Apple weren't doing that. So 
it's an important component.
    Let me close by saying that many of us look forward to the 
day when not only AIDS and malaria, but the broad sweep of 
global health development and poverty alleviation is seen as 
critical to the U.S. engagement with the world. We strongly 
endorse continued and growing support of vital agencies, like 
the Global Fund, and recognize that the United States must 
provide its fair share of funding for international and 
multilateral activities. We also hope someday to see a 
Department of International Development. It is as vital to 
America's interests in the world as our diplomatic and military 
engagements, but that's for another hearing. [Laughter.]
    Dr. Daulaire. Thank you very much.
    [The prepared statement of Dr. Daulaire follows:]

Prepared Statement of Nils Daulaire, M.D., MPH, President & CEO, Global 
                     Health Council, Washington, DC

    Chairman Menendez and members of the committee, thank you for 
holding this important hearing today on the future of the United States 
response to global AIDS, tuberculosis, and malaria. I am Dr. Nils 
Daulaire, President and CEO of the Global Health Council, the world's 
largest membership alliance of over 5,000 health professionals and 480 
service organizations working to save lives and improve health 
throughout the world.
    Before I begin my remarks, let me applaud this committee for its 
commitment and dedication to global health issues, most notably HIV/
AIDS. I congratulate the committee for its bipartisan work on the 
United States Leadership Act Against HIV/AIDS, Tuberculosis and 
Malaria, the law that authorized the President's Emergency Program for 
AIDS Relief--PEPFAR. This historic legislation set the stage for an 
unprecedented U.S. Government investment in the fight against a serious 
global health challenge. The importance of this massive investment 
cannot be overstated; it has literally transformed the concept of what 
is possible in the realm of global health. On behalf of the Council's 
members working in over 100 countries across the globe, and the 
millions whose lives are improved by U.S. Government-supported global 
health programs, we thank you.
    The Global Health Council's members include nonprofit service 
organizations, faith-based organizations, schools of public health and 
medicine, research institutions, associations, foundations, private 
businesses and concerned global citizens whose work puts them on the 
front lines of global health--delivering programs, building capacity, 
developing new tools and technologies, and evaluating impact to improve 
health among the world's poorest citizens. Our members work on a wide 
array of issues, including, of course, HIV/AIDS, but also other 
infectious diseases, child and maternal health, family planning, water 
and sanitation, and health systems strengthening.
    I am a physician and have been personally engaged for more than 
three decades in the global effort to improve the health of the poor. 
When AIDS was first recognized just 26 years ago, few anticipated that 
it would grow to become the worst pandemic of modern times, and the 
world's initial slow response gave the virus a chance to establish its 
death grip on the lives of millions. But the past decade has been 
heartening to those of us who have taken on the challenge of building 
health programs and services in the forgotten corners of the world. 
U.S. leaders, as well as leaders from other countries; the U.N.; the 
Global Fund to Fight AIDS, TB, and Malaria; and the Bill and Melinda 
Gates Foundation, have recognized both the severity and the moral call 
of HIV/AIDS, and the response has been unprecedented.
    In fact, the response has begun to make a difference. As UNAIDS 
recently reported, new data show that the global HIV prevalence--the 
percentage of people living with HIV--has leveled off and that the 
number of new infections each year has fallen, in part as a result of 
the impact of HIV programs. However, in 2007 33.2 million [30.6-36.1 
million] people were estimated to be living with HIV, 2.5 million [1.8-
4.1 million] people became newly infected and 2.1 million [1.9-2.4 
million] people died of AIDS.\1\ When the reality is that every person 
with a new infection will need years of treatment and care, it remains 
clear that now is not the time to step back from U.S. leadership on 
this issue.
    We need to continue the signal accomplishment of this new century--
PEPFAR--the partnership between the Bush administration and a solid 
bipartisan majority of the U.S. Congress that made PEPFAR the 
cornerstone of the largest prevention, care and treatment effort the 
world has ever seen. It is clear that PEPFAR has had some enormous 
successes over the last 4 years. We are here today in order to build on 
them and to make them lasting.
    The things that have worked well need to be reinforced, and those 
that haven't worked so well need to be fixed. The reauthorization 
process provides us with an opportunity to examine ways to make this 
program more effective for the long run. To help provide constructive 
and informed input into the PEPFAR reauthorization process, the Global 
Health Council has for months now engaged a wide network of experts, 
implementers, and advocates through the Global AIDS Roundtable and the 
more programmatic HIV Implementers Group. We look forward to continuing 
our work with this committee to ensure that the next generation of this 
program continues its forward momentum.
    This administration's commitment to the fight against the global 
spread of HIV/AIDS has resulted in extraordinary accomplishments. 
Similarly impressive efforts have begun for malaria under the 
President's Malaria Initiative (PMI). But one thing is clear to those 
of us who engage daily in delivering these services: While an emergency 
response focused on a single disease can have remarkable, short-term 
results, it will not succeed as a model for the long-term response that 
is necessary for reversing the HIV/AIDS pandemic.
    Early in his tenure, the President's first Global AIDS Coordinator, 
Ambassador Randall Tobias, was asked about the inter-relationships 
between the HIV/AIDS response and other public health interventions 
such as maternal and child health, family planning, nutrition, clean 
water, and other diseases. His response was to acknowledge that these 
were important problems, but that his charter was to combat HIV/AIDS 
through the sharp lens of prevention, care and treatment. Congress had 
set very ambitious targets, he told us, and he had to stay completely 
focused on them.\2\
    His point was understandable. But I believe that, with experience, 
that view was short-sighted, a mistake of first principles. Over the 
past few years, it has become very apparent that, in the long run, we 
cannot succeed in our efforts against HIV/AIDS without linking PEPFAR 
much more closely with these other interventions and with strengthening 
health systems more broadly.
    Let me take as an example the issue of newborn infection with HIV, 
a preventable tragedy that occurs over half a million times a year.\3\ 
PEPFAR addresses this through a program to test pregnant women and 
provide those who are HIV positive the drug nevirapine, a low-cost 
highly effective intervention. This has been a priority program under 
PEPFAR. Yet throughout the world, most women are never tested for HIV, 
a small proportion of those who could benefit receive nevirapine, only 
a small dent has been made in the numbers of infected children born in 
poor countries, and even less impact has been seen on overall child 
death rates.3,5 Why is this?
    First, because women generally come to the health care system in 
the first place not for HIV care but for routine family planning and 
maternal and child health care.\6\ Most of them don't even know they 
are HIV positive. So unless the HIV services are deeply integrated with 
family planning and maternal and child health services, most who need 
them will never know they need them, much less get them.
    These women need help not just with their HIV infections. Their 
first priority is for a safe pregnancy and delivery. They and their 
newborns need to sleep under malaria bed nets. They need access to 
nutritious food. They need to know how they can prevent or delay their 
next pregnancy.
    And their babies, whether HIV infected or not, need basic newborn 
and childhood care. After all, most children who die, even most 
children dying as a consequence of HIV infection, die from diarrhea, 
pneumonia, malaria, and other common preventable or treatable childhood 
diseases.\7\ Antiretroviral drugs alone can't save HIV-positive babies 
without the child health services that are currently not available 
because resources and manpower are being redirected toward HIV/AIDS.
    The Global AIDS Coordinator, Ambassador Mark Dybul, acknowledges 
this reality, and has begun to explore programmatic linkages. I think 
he could use some help, and I believe that the Congress can provide 
that help by granting specific authority for, and even requiring, the 
Global AIDS Coordinator to link directly to the other U.S. agencies and 
programs that deliver these services and, when they are weak or 
inadequate, to support them directly with PEPFAR funds. Far from being 
a diversion of resources, this would assure that our HIV/AIDS dollars 
are spent most effectively.
    Should PEPFAR then be the platform for all basic health services or 
bear the programmatic burden for the full array of health issues facing 
communities in the developing world? No. The appropriate U.S. policy 
approach must encompass, but not be based upon, responses to any single 
    I will return to specific thoughts on PEPFAR reauthorization in a 
moment. But let me first offer you the bottom line here: While beyond 
the scope of this hearing alone, the U.S. Government ultimately needs a 
comprehensive strategy to guide its engagement in improving the health 
of the world's citizens and, in turn, protecting the health of its own. 
This is my fifth appearance before Congress this year. I have testified 
about maternal and child health, malaria, tuberculosis, and HIV/AIDS. I 
appreciate the opportunity to share perspective on each of these 
topics, but budget line items and various agency authorities have 
dissected a single experience--health--into disparate funding, 
policies, and programmatic approaches that undermine our ultimate goal: 
Healthier individuals and families and therefore more stable and 
productive global communities. Investing in health is not just a 
humanitarian response. The returns on its investments are also seen in 
growing and stable political systems. With U.S. Government investments 
in global health on the order of $6 billion (with nearly $5 billion 
committed to AIDS alone), don't we want to make the most of our 
investment? \8\ I have been at this for decades, and I can tell you 
with confidence that single-disease, single-intervention, or any other 
siloed approach simply will not succeed over the long run.
    This hearing is about transitioning the U.S. response to the global 
AIDS crisis through PEPFAR from an emergency program to a sustainable 
one, because we recognize that the AIDS virus will be in our midst for 
generations to come. Our response to HIV/AIDS must now expand from a 
model designed to help get the emergency room up and running to one 
where the community clinic can successfully keep people out of the 
emergency room in the first place.
    Of course, HIV-affected people must have access to antiretroviral 
drugs, but no one can survive on drugs alone. Just like everyone else, 
people who are living with HIV/AIDS--especially those who have gotten 
drugs to keep their infections in check--need good nutrition, clean 
water, vaccines, pre- and post-natal care for mothers and children and 
prevention, care and treatment for all the other major health threats 
that they face.
    Let's face it, we are in a struggle to beat HIV/AIDS for the long 
haul--just like our battles to overcome cancer and heart disease at 
home. Now that HIV/AIDS is treatable, it has become a chronic disease, 
and chronic diseases require functioning health systems, working every 
day.9,10 Clinics must be open, staffed, and supplied--and 
that can't be done just for HIV alone. Health providers must be 
trained, supervised, supported, and paid--and no one dreams that this 
could be an AIDS-specific cadre. Ministries of health and 
nongovernmental organizations alike must function smoothly and 
efficiently, with solid leadership and management skills--and these 
must be generalized skills because the systems they must support are 
necessary for each and every health intervention.
    This is why beating HIV/AIDS demands more than HIV-specific 
prevention, care and treatment programs operating in isolation from 
other global health interventions. This is why the delivery of all 
essential health care services through strong and efficient health 
systems is necessary for the fight against AIDS. This is why greater 
integration and coordination of PEPFAR programs with other global 
health programs and services is the single-most important step the U.S. 
can take right now to maximize the program's effectiveness in the 
future. I call on Congress to make sure that this is supported and 
encouraged in your reauthorization bill.
    PEPFAR can and should be better integrated on four different 

   Internally between its own prevention, treatment and care 
   Laterally across other U.S. global health programs 
        addressing issues other than HIV;
   Nationally through the strengthening of health systems and 
        support of expanded health manpower in countries with high 
        burdens of disease; and
   Externally through enhanced coordination between PEPFAR and 
        other HIV- and non-HIV specific programs managed by focus 
        country governments and by other international donors.

                          internal integration

    To date, PEPFAR's programs have been separated into the categories 
of prevention, treatment or care, with the focus and lion's share of 
funding largely on treatment. This approach can work with certain 
targeted populations, but there is always the risk that this 
construction will prove too rigid to optimize the use of resources and 
most effectively save lives.
    Those who are at high risk of contracting HIV need to know how to 
stay HIV free and what treatment options exist if they do become 
infected. Those who are HIV positive need to have access to the full 
range of prevention methods in order to improve their own health and to 
protect the health of those around them. It remains fundamentally true 
that treatment for people who are HIV positive still needs to be 
expanded, but as we find that for every individual treated there are 
six new infections, it is clear that we will never be able to treat our 
way out of this epidemic. Prevention activities must be significantly 
scaled up and built upon interventions that go beyond medical models to 
address the behavioral and social components of this disease.
    I would be remiss if I did not flag two provisions within the 
current legislation that, if left unrevised, will undermine prevention, 
care and treatment activities. The first provision is the specific 
target that one-third of prevention funds be dedicated to abstinence-
until-marriage activities. In communities where many young girls' first 
sexual encounter is by force or where being a young bride to an older 
man who has not limited his sexual encounters is the cultural norm, the 
current abstinence policy does not move us toward the desired 
outcomes--fewer HIV infections. Delayed sexual debut is ideal. However, 
a fundamental tenet of public health is that you tailor the 
intervention to local circumstances. A blanket abstinence target 
ignores this tenet and leaves too many young women without realistic 
recourse to protect their health.
    The second provision is the antiprostitution pledge which all 
organizations receiving PEPFAR funds must sign. This provision must be 
repealed. Although not politically correct, the truth is that in many 
areas including India, Thailand, and the former Soviet Union the AIDS 
epidemic is driven in part by high-risk behaviors such as commercial 
sex work. Ideally, individuals would not engage in these activities. 
But, we cannot let the epidemic continue to spread because we take 
ideological issue with the behavior of a subset of men and women. Let 
us not tie the hands of organizations that are committed to providing 
the best interventions for people in their very real, complex, 
imperfect yet valuable lives. I strongly encourage the committee to 
consider the social and cultural complexities of the lives of people 
who experience this epidemic and to program accordingly.
    integration and coordination across u.s. global health programs
    Most people who are battling AIDS actually die from infections 
caused by other organisms that have found an open door due to HIV's 
suppression of the immune system; these are called Opportunistic 
Infections (OIs). Currently, tuberculosis (TB) kills about one-third of 
AIDS victims.\11\ Pregnant women who contract malaria are at greater 
risk of HIV infection and those who are HIV-positive are at greater 
risk of malaria.3,12 And as I have noted, most children 
dying with HIV die as a direct result of common childhood infections 
whether or not their immune systems are compromised.\13\
    By only addressing the HIV/AIDS-specific aspects of the health of a 
person with coinfections and multiple susceptibilities, PEPFAR is, in 
some ways, saving lives only to leave them vulnerable to death or 
debilitating illness from other causes whose effects could have been 
minimized or eliminated with a more thoughtful and thorough 
programmatic response. A more comprehensive view of multiple disease 
risk and the appropriate response is needed. PEPFAR programs must have 
explicit linkages between their services and those other critical 
global health programs that focus on other diseases and health 
    A number of our member organizations do an excellent example of 
integrating HIV/AIDS programs with other health and development 
efforts. CARE has done some enormously creative and productive work 
toward that end. Family Health International (FHI) has also 
demonstrated the positive impact of an integrated response. A number of 
other Global Health Council members are engaged with RAPIDS--a PEPFAR-
funded project that covers 53 districts in Zambia to provide home- and 
community-based care for people living with HIV/AIDS and support for 
orphans and vulnerable children through a coordinated response.\15\ In 
this example of successful coordination across U.S. programs, USAID, 
CDC, DOD, Peace Corps, and the State Department have developed an 
intense, integrated, and coordinated response in which it funded 
various organizations to take on projects that cut across all sectors. 
The project funds agriculture, economic growth, health, education and 
democracy while at the same time aiming to scale up prevention, 
treatment and care. As a result, thousands of people living with HIV in 
Zambia are accessing basic health and development services, and not 
just antiretroviral therapy.
    When PEPFAR was first announced, it was with assurances that this 
funding would be additive to funds already in place for global health 
and international development efforts. Sadly, we are seeing instances, 
such as in Ethiopia, in which PEPFAR and PMI funds have increased, 
while maternal and child health funds have been significantly cut.\16\ 
Can the majority of that country's women and children who are dying 
despite being HIV-free, and whose deaths could readily be averted with 
effective, proven, low-cost interventions, consider this a victory?

       strengthening health systems and building health manpower

    HIV/AIDS has taken weak health systems in the most highly afflicted 
countries, particularly those in sub-Saharan Africa, and stressed them 
to the point of collapse. A major contribution of PEPFAR was revealing 
the utterly desperate conditions of the world's national health 
systems. Once money and resources began to flow, we quickly realized 
that we lacked the trained professionals to deliver life-saving 
interventions; we lacked the management systems to implement programs 
and handle large infusions of resources--nearly every link in the 
health system left something to be desired. Weak health infrastructure 
and lack of an adequate human resource supply in developing countries 
limit the ability to support the integration and coordination of HIV/
AIDS services.
    While there is much to be done, perhaps the most pressing issue is 
the supply, type and training of health workers, particularly in the 
areas of expanding prevention services and detecting opportunistic 
infections. As the Institute of Medicine (IOM) recommends, PEPFAR must 
contribute to strengthening health systems and adequately train and 
support critically needed new health workers.\17\

   external coordination between pepfar and non-u.s. hiv and non-hiv 

    Coordination is absolutely necessary within programs of the U.S. 
Government. It is also essential with the governments of focus 
countries if we are to continue to build upon PEPFAR's successes. 
According to the IOM's report, PEPFAR country teams ``have been largely 
successful in aligning their plans'' with a recipient country's 
national HIV/AIDS strategies.\18\ Serious concerns remain, however, 
about ensuring that the siren call of available PEPFAR resources 
doesn't result in situations where national HIV/AIDS strategies become 
seriously misaligned in proportion to countries' specific disease 
    When lives are at stake every dollar has to count. The U.S. 
Government also must take care to chart whether other public or private 
donors are investing in the same kinds of programs and in the same 
places as PEPFAR so that duplication--or worse, destructive 
competition--is avoided.
    Any discussion about vital coordination between PEPFAR and other 
HIV/AIDS efforts is incomplete without mention of the other cornerstone 
of the global response to this pandemic: The Global Fund to Fight AIDS, 
TB and Malaria. Early years saw aspects of unproductive competition 
between PEPFAR and the Global Fund. I applaud Ambassador Dybul for his 
efforts to assure closer coordination and cooperation with the Global 
Fund, and encourage efforts to assure that this continues and is 
expanded, since each of these mechanisms has its own particular 
strengths and advantages.\19\
    Successful multidonor coordination on HIV/AIDS programs is not only 
possible, it makes for better programs. In Malawi, the U.K.'s 
Department for International Development, the Global Fund to Fight 
AIDS, TB and Malaria, and Malawi's Ministry of Health together designed 
the Emergency Human Resource Plan to build human resource capacity to 
address the severe HIV/AIDS crisis in the country. This joint planning 
and coordination helped Malawi to double its output of nurses in just 3 
years and increase preservice training for doctors. The strategic 
coordination avoided duplicative efforts, allowing the program to 
address a wide range of problems related to health systems.\20\

                            looking forward

    Even with its remarkable accomplishments over the past 4 years, 
PEPFAR faces an uphill battle against a virus that manages to stay 
ahead of the world's best efforts to defeat it. Just a few months ago, 
we heard about the failure of what had been considered our most 
promising vaccine candidate.\21\ There is no doubt that more 
disappointments will follow. This will be a long struggle requiring 
persistence and patience.
    As PEPFAR evolves with Congress's oversight, a number of issues 
must be addressed. First, the structure of U.S. global health 
assistance must be seriously reviewed and, I would recommend, 
redesigned. Each agency currently working as a part of the U.S. global 
AIDS response has a separate funding and procurement mechanism, 
different benchmarks for reporting, and different targeted communities. 
Under the current model, coordination and integration of HIV/AIDS is 
more difficult than it needs to be. Congress should take steps to 
correct this.
    Congress must also assure that health systems and health manpower 
development are front and center in expanded efforts to address HIV/
AIDS and other major causes of ill-health and death in highly affected 
    Finally, the U.S., other donors, and national governments must take 
under serious consideration the financial implications of a sustainable 
response to global AIDS, specifically, and basic health more broadly. 
While U.S. funding for global AIDS grew from $125 million in 1997 to 
$5.4 billion in 2007, it still remains below the levels needed for 
fully scaling up prevention and treatment in the focus countries, much 
less the need for HIV/AIDS services in nonfocus countries where 
millions of people are infected or at-risk.\22\ Treatment costs will 
rise with the need for second-line drugs and HIV-positive individuals 
living longer and requiring a wider array of health services.\4\ 
Effective and widespread prevention services, although a wise long-term 
investment, will add significant costs.
    This need for expanded funding will continue from a finite pool of 
resources. Still, the funding currently available for global AIDS 
programs dwarfs the U.S. investments currently made in other global 
health programs. For example, USAID's child and maternal health and 
reproductive health accounts have remained at around $360 million and 
$400 million a year respectively, and yet three times as many children 
and women die globally each year from non-HIV related causes than from 
AIDS.23,24 Resource constraints as well as policy 
restrictions have impeded the successful ``wrap around'' of non-HIV 
services with HIV services.
    Increased support for global AIDS programs must not come at the 
expense of other global health programs if we are to achieve both the 
goal of establishing an effective HIV/AIDS program and the goal of 
building comprehensive and efficient national approaches to all major 
global health threats.


    The President's Emergency Plan for AIDS Relief may be relatively 
new, but the fight against the global spread of HIV/AIDS is not. We 
have reached a point where the emergency response is still necessary 
but no longer sufficient in our fight against HIV/AIDS. HIV/AIDS is 
inextricably linked with other diseases. To effectively combat this 
pandemic, we must expand our response, and a comprehensive approach to 
global health in developing countries is needed to do that 
    Today, I have proposed steps that could be taken in the near future 
to strengthen PEPFAR by better integrating PEPFAR services internally, 
across U.S. global health programs, with national health systems, and 
with external partners addressing HIV/AIDS in the developing world. We 
can improve upon the lessons learned through PEPFAR to improve our 
global AIDS response and reverse the HIV/AIDS pandemic.
    In the long term, I urge Congress and the administration to also 
consider the role of PEPFAR in the context of developing a 
comprehensive U.S. strategy for addressing all critical global health 
issues. The Global Health Council and our members stand prepared to 
help address the realities in which a third of the world's people 
live--and in which a disproportionate number die.
    Thank you again for the opportunity to testify before you today. I 
welcome your questions.

    \1\ UNAIDS, World Health Organization. 2007. AIDS Epidemic Update. 
Available from: http://data.unaids.org/pub/EPISlides/2007/
    \2\ H.R. 1928. United States Leadership Against HIV/AIDS, 
Tuberculosis and Malaria Act of 2003. Public Law 108-25. Available 
from: http://thomas.loc.gov/.
    \3\ UNAIDS, World Health Organization. 2006. AIDS Epidemic Update: 
December 2006. Available from: http://www.unaids.org/en/HIV_data/
    \4\ World Health Organization. 2007. Towards Universal Access: 
Scaling Up Priority HIV/AIDS Interventions in the Health Sector. 
Available from: http://www.who.int/hiv/mediacentre/
    \5\ Global Health Council. 2007. Our Global Responsibility to the 
World's Children. Available from: http://www.globalhealth.org/images/
    \6\ World Health Organization. 2005. World Health Report 2005: Make 
Every Mother and Child Count. Geneva: WHO. Available from: http://
    \7\ Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child Health 
Epidemiology Reference Group. 2005. WHO Estimates the Causes of Death 
in Children. Lancet 365(9465):1147-52.
    \8\ Global Health Council. 2007. Global Health Funding. Available 
from: http://www.globalhealth.org/view_top.php3?id=172.
    \9\ Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et 
al. 2004. Overcoming Health-Systems Constraints To Achieve the 
Millennium Development Goals. Lancet 364:900-6.
    \10\ World Health Organization. 2006. World Health Report 2006: 
Working Together for Health. Geneva: WHO. Available from: http://
    \11\ World Health Organization. Joint HIV/Tuberculosis 
Interventions. (Accessed September 24, 2007). Available from: http://
    \12\ Breman J, Alilio M, Mills A. 2004. Conquering the Intolerable 
Burden of Malaria: What's New, What's Needed: A Summary. American 
Journal of Tropical Medicine & Hygiene 71:1-15.
    \13\ Prendergast A, Tudor-Williams G, Burchett S, Goulder P. 2007. 
International Perspectives, Progress, and Future Challenges of 
Paediatric HIV Infection. Lancet 370:68-80.
    \14\ Reynolds H, Janowitz B, Homan R, Johnson L. 2006. The Value of 
Contraception To Prevent Perinatal HIV Transmission. Sexually 
Transmitted Diseases 33(6):350-6.
    \15\ USAID. HIV/AIDS multisector. (Accessed September 20, 2007), 
RAPIDS. Available from: http://www.usaid.gov/zm/hiv/hiv.htm.
    \16\ Global Health Council. 2007. Global Health Spending: An 
Analysis of the President's Fiscal Year 2008 Budget Request. Available 
from: http://www.globalhealth.org/.
    \17\ Institute of Medicine. 2007. PEPFAR Implementation: Progress 
and Promise Report Brief. Available from:http://www.iom.edu/
    \18\ Sepulveda J, Carpenter C, Curran J, Holzemer W, Smits H, Scott 
K, et al., editors. PEPFAR Implementation: Progress and Promise. 
Washington, DC: Institute of Medicine, 2007.
    \19\ Wakabi W. 2007. Global Health Agencies Agree to HIV/AIDS 
Partnership. Lancet 370:
    \20\ Medecins San Frontieres. 2007. Help Wanted: Confronting the 
Health Care Worker Crisis To Expand Access to HIV/AIDS Treatment, the 
MSF Experience in South Africa. Available from: http://www.msf.org/
source/countries/africa/southafrica/2007/Help wanted.pdf.
    \21\ Kaiser Family Foundation. Merck Halts International HIV 
Vaccine Trial. Kaiser daily HIV/AIDS report. September 24, 2007. 
Available from: http://www.kaisernetwork.org/daily_reports/
    \22\ Global Health Council. 2007. 10-year chart explanation. 
Available from: http://www.globalhealth.org.
    \23\ U.S. Appropriations 1997-2007. 2007 (Accessed March 12, 2007), 
Available from: http://www.thomas.gov/.
    \24\ World Health Organization. 2004. WHO Global Burden of Disease 
(GBD) 2002 Estimates (revised). Available from: www.who.int/healthinfo/

    Senator Menendez. Thank you.
    Mr. Hackett.

                         BALTIMORE, MD

    Mr. Hackett. Thank you very much, Chairman Menendez and 
Ranking Member Lugar, Senator Sununu, and Senator Kerry. Thank 
you for allowing us to be here and share our perspectives on 
the next phase of PEPFAR and the global fight on AIDS.
    I'm president of Catholic Relief Services, an organization 
which reaches out around the world to assist people in their 
state of poverty, and to try to give them the dignity and the 
help to rise above it.
    We have been involved in addressing the HIV and AIDS 
questions and pandemic for more than 20 years. I must admit, we 
haven't done enough, or we haven't done it well enough. But, 
through PEPFAR, CRS, and our partners are providing 
antiretroviral therapy to 100,000 people and care right now to 
nearly a quarter of a million people living with HIV and AIDS 
in 12 out of the 15 focus countries. And we're also engaged in 
40 other countries with our own private funds, nongovernmental 
funds, in reaching out and providing assistance to people 
living with AIDS.
    Let me echo what my colleagues have said before. I believe 
that PEPFAR is an outstanding success for which the President, 
this Congress, and the American people can be most proud. The 
strong leadership and broad bipartisan support have resulted in 
an initiative that shows the best possible face of the American 
    PEPFAR has come through its gestation period. It was, at 
times, difficult, I'll tell you that. But now it is through it, 
and it's ready to take off. PEPFAR is, above all, a program of 
    Just 2 weeks ago, during the World AIDS Day commemorations 
here in Washington, President Bush literally embraced a woman 
from Zambia by the name of Bridget Chisenga. Everybody who 
knows Bridget calls her ``Auntie Bridget.'' She actually works 
for us in Zambia, promoting adherence to antiretroviral therapy 
and fighting stigma associated with AIDS. She gave President 
Bush a message that seemed to move him and caused him to 
embrace her. She said, ``I've seen the Lazarus effect. I've 
seen people coming back to life.'' Auntie Bridget isn't just a 
PEPFAR implementer, she's also receiving antiretroviral therapy 
through the PEPFAR program; and, without PEPFAR, she and many 
millions of others would not be alive. She herself was part of 
that Lazarus effect.
    The HIV prevention efforts that are part of PEPFAR have 
also shown progress, particularly through the AB model of 
``abstinence and be faithful.'' Data about the effectiveness of 
abstinence and faithfulness have been largely ignored. However, 
there is a widespread consensus among many public health 
experts that partner reduction and the delay of sexual debut 
are critical and necessary components of any comprehensive 
approach to reduce the spread of AIDS.
    Finally, I'd like to share some of what we consider to be 
the key issues for the next phase of PEPFAR.
    First, I think we've learned how to control the disease. 
Now we must put adequate resources into initiatives that treat 
and prevent HIV. And we are now in a position to really pick up 
the momentum. ``We,'' in that context, are that range of 
agencies that are out there on the front lines, in the villages 
beyond the end of the road, that are providing assistance.
    Second, it's important to create linkages between PEPFAR 
and other U.S. assistance programs, particularly in the areas 
of nutrition, of livelihood, of income generating and 
education. And we'd like to emphasize that these complementary 
needs should be funded through other accounts, not through 
PEPFAR, but they should be coordinated at the country level.
    Third, our model focuses on long-term sustainable 
development by building the capacity of local partners. That 
includes physicians and health care staff. But it will be a 
long time, in the poorest of countries, before they can really 
completely and independently take on the burden of addressing 
this pandemic. And, until then, providing these vital services 
through PEPFAR is the right thing to do.
    Fourth, because we believe that PEPFAR, as implemented, 
has, so far, been widely successful, we urge you to preserve 
the basic programming model, but with several improvements. 
First, we feel that there must be a provision to maintain 
funding for abstinence and faithfulness programs. Without 
dedicated funding, these activities will be ignored. We've seen 
it before, we've been down that road before, and, until there 
was dedicated funding, we just couldn't access those programs.
    Second, do not require PEPFAR implementers to offer family 
planning and reproductive services. Such a requirement runs 
counter to the moral values of some organizations, and may 
constrain or hinder some organizations from participating in 
the program. That will mean the program will not be offered to 
many millions of people.
    Third, the therapeutic feeding program, called Food by 
Prescription, should be expanded to all PEPFAR countries 
providing antiretroviral therapy.
    Fourth, increase the support in PEPFAR for children, 
including pediatric antiretroviral therapy and assistance for 
orphans and vulnerable children.
    And, finally, maintain the centralized model for 
implementing antiretroviral therapy within PEPFAR.
    In conclusion, I'd like to, once again, express my 
appreciation to you, Mr. Chairman and Ranking Member Lugar and 
all of the members of the committee, for calling this hearing 
to discuss the next phase of this--what we consider a most 
successful program, one of which our Nation can be proud. We 
urge timely authorization of this initiative so that the vital 
health of some of the world's poorest and most vulnerable 
people can be sustained and improved.
    I'd be happy to take any questions, as well. Thank you.
    [The prepared statement of Mr. Hackett follows:]

Prepared Statement of Ken Hackett, President, Catholic Relief Services, 
                             Baltimore, MD

    Good afternoon Chairman Menendez, Ranking Member Lugar, and members 
of the committee. I commend you for calling this timely hearing and 
giving Catholic Relief Services the opportunity to share our 
experiences as an implementer of the President's Emergency Plan for 
AIDS Relief (PEPFAR) programs.
    My name is Ken Hackett, President of Catholic Relief Services 
(CRS). For over 60 years and currently operating in more than 100 
countries, CRS--the international relief and development agency of the 
United States Conference of Catholic Bishops--has been responding to 
the needs of people around the world in emergencies, humanitarian 
crises, and in development--especially for the poor, marginalized, and 
disenfranchised in the developing world. CRS has supported HIV and AIDS 
interventions for more than 20 years, almost since the beginning of the 
pandemic. Our 250 HIV and AIDS projects in 52 countries provide 
comprehensive and holistic services for orphans and other vulnerable 
children (OVC), home-based care, antiretroviral therapy (ART), other 
treatment support, education for religious leaders on HIV and AIDS and 
stigma reduction, and prevention education for sexually transmitted 
HIV--focusing on promotion of abstinence and behavior change.

                          successes of pepfar

    First and foremost, let me say that PEPFAR is one of the most 
outstanding programs our government has ever created. Strong leadership 
and broad bipartisan support have shown the best possible face of the 
U.S. Government toward our world neighbors, and reflect the 
overwhelming compassion and generosity of the American people toward 
those affected by HIV and AIDS. And above all, PEPFAR is working. In a 
relatively short time, this massive new program was put in place and is 
literally saving lives everyday.
    I remember returning to Kenya in 1992 after a 7-year absence, and 
hearing that so many of the Kenyans I had known had died. When I asked 
why, I was told it was tuberculosis or pneumonia. But when I probed a 
little deeper, I found they had died of AIDS. It was absolutely 
shocking. In those days, AIDS was a death sentence.
    In contrast, just 2 weeks ago, during a World AIDS Day 
commemoration, President Bush embraced someone the Washington Post 
called ``a regal-looking Zambian woman.'' Her name is Bridget Chisenga, 
but everybody who knows her calls her ``Auntie Bridget.'' She works for 
CRS in Zambia promoting adherence to ART and fighting stigma associated 
with HIV. She gave President Bush a message that seemed to move him: 
``I've seen the Lazarus effect,'' she said. ``I have seen hopes being 
raised. I have seen people coming back to life. And my message is, `We 
are celebrating life to the fullest.' ''
    But Auntie Bridget is not just a crusader and implementer for 
PEPFAR--she is also receiving the same antiretroviral therapy as the 
people she counsels. Without PEPFAR, Auntie Bridget would not be alive. 
She is a beneficiary of the PEPFAR transformation.
    Now PEPFAR is providing life-saving ART for nearly 1.5 million men, 
women, and children in 15 countries in Africa, Asia, and the Caribbean. 
It has supported outreach activities to more than 61.5 million people 
to prevent sexual transmission of HIV. It is providing care and support 
for more than 2.7 million orphans and vulnerable children, and more 
than 4 million people living with HIV and AIDS.\1\ This is nothing 
short of astounding. This miracle is being repeated thousand of times 
as antiretroviral therapy provided through PEPFAR is bringing hope 
where there was none. A complicated medical solution is now available 
to the poorest and most vulnerable people living in very remote areas.
    \1\ From Statement of Ambassador Mark Dybul, U.S. Global AIDS 
Coordinator, Before the Committee on Foreign Relations, United States 
Senate, Washington, DC, October 24, 2007. http://www.senate.gov/
    And there are other benefits as well. This successful treatment 
offered through PEPFAR has actually become part of the prevention 
strategy. The fact that people are beginning to live with this disease, 
returning to their families and resuming their livelihoods, has reduced 
stigma in communities and has encouraged others to get tested for HIV.

            catholic relief services' experience with pepfar

    Mr. Chairman, members of the committee, CRS has responded to the 
emergency of the HIV and AIDS pandemic as we do in all our emergency 
responses--with deliberate local capacity-building of existing partners 
and with an eye toward long-term sustainable development.
    CRS' work is built on a vision rooted in the Church's teaching that 
values human life and promotes human dignity. The local Catholic Church 
is often our primary partner, and we work at the invitation of the 
local Catholic Bishops' conference in each country. However, we also 
work with partners of other faiths, as well as other nongovernmental 
and local community-based organizations to serve people based solely on 
need, regardless of their race, religion, or ethnicity.
    CRS works through local church and religious partners because of 
their extensive network and reach. Every community in the world has a 
community of faith with credible leadership. Working with them and 
other local community-based organizations assures that programs are 
grounded in the local communities' reality. Equally important, this 
extensive network of contacts ensures the widespread delivery of 
comprehensive HIV treatment, prevention, and support programs.
    HIV and AIDS programming is a major priority for Catholic Relief 
Services. Our FY 2008 HIV and AIDS budget of $171 million will account 
for nearly a third of the agency's annual programmatic expenses 
overseas.\2\ With projects in 12 of the 15 PEPFAR focus countries, we 
are a major implementer of PEPFAR programs.\3\
    \2\ 57 percent ($98 million) projected to come from PEPFAR.
    \3\ Ivory Coast, Namibia, and Mozambique are the only PEPFAR focal 
countries where CRS does not have PEPFAR programs--because we do not 
work in those countries at this time.
    Our largest PEPFAR award--AIDSRelief--is a $335 million CRS-led 
consortium that includes the Institute of Human Virology of the 
University of Maryland, Constella Futures, Catholic Medical Mission 
Board, and IMA World Health. AIDSRelief provides ART in nine PEPFAR 
focus countries by building the capacity of 164 local partners--the 
majority of them local faith-based health care providers. As of 31 
October 2007, over 90,000 people are on ART and almost 146,000 are 
enrolled in care and support services. AIDSRelief has exceeded its 
overall targets each year of the grant to date.
    Our model of care trains and mentors, local physicians, and health 
care staff to better manage high-quality treatment services to a 
growing number of patients. These locally trained community health 
workers and volunteer and paid treatment coaches and expert patients 
are expanding followup and support services for stabilized patients in 
the community. Many of the health care institutions we support now are 
exhibiting their growing capacity to access resources through the 
Global Fund locally and through other international donors. However, it 
will be a long time before the poorest countries of the world can 
completely and independently take on this burden. Until then, providing 
these vital services through PEPFAR is the right thing to do.
    More than half of the AIDSRelief treatment sites are in rural areas 
where ART services would otherwise be unavailable. In war torn northern 
Uganda, where moving around safely is difficult, AIDSRelief is one of 
the few organizations supporting ART through local faith-based 
institutions. For the past 2 years, AIDSRelief has partnered with Dr. 
Ambrosoli Memorial Hospital in Kalongo where 302 patients are on ART 
and 1,246 receive care. And in Kassesse District, a remote mountainous 
area in western Uganda, AIDSRelief was the first to support the 
delivery of antiretroviral therapy in a health center run by the 
Banyatereza Sisters. Often walking long distances, the Sisters have 
developed an extensive community outreach program reaching 324 patients 
on ART and 725 in care. Without PEPFAR, these people would not have 
access to this life-saving treatment. In fact, without the ministry and 
care of this faith-based hospital and this religious community, the 
local population would probably not have access to health care at all.
    Catholic Relief Services currently operates a $9 million, 5-year, 
PEPFAR-supported Orphans and Vulnerable Children Program that provides 
quality services to children in Botswana, Haiti, Kenya, Rwanda, 
Tanzania, and Zambia. As of 30 September 2007, this program is reaching 
56,066 OVC, exceeding cumulative FY07 targets. The program provides 
education and vocational training, health care, psychosocial support, 
food and nutrition, protection services, shelter and care, and economic 
    Our third PEPFAR central award addresses prevention of sexually 
transmitted HIV programming through age-appropriate abstinence and 
behavior change among youth in three focus countries--Rwanda, Ethiopia, 
and Uganda. Drawing upon extensive experience in HIV prevention in the 
target countries, as well as similar programs in more than 30 other CRS 
prevention programs worldwide, the ``Avoiding Risk, Affirming Life'' 
prevention program works with a broad range of faith- and community-
based partners that share CRS' commitment to equip youth with the 
values, attitudes, skills, and support to either abstain from sex prior 
to marriage or recommit to abstinence before marriage, and then to 
remain faithful in marriage. As of 30 September 2007, the program has 
provided 346,768 youth and adults with information to help them make 
informed decisions about sexual behaviors and encourage health-seeking 
    In addition to these PEPFAR central awards, we also have received 
numerous country-specific mission level grants to provide more or 
additional HIV services.

                     challenges and recommendations

    PEPFAR programs in which CRS is involved have all been successful--
often exceeding their targets. They have all faced numerous 
challenges--and overcome them. However, there are certain broader and 
more systemic challenges that need to be addressed by Congress as it 
prepares to reauthorize PEPFAR.

   Prevention: HIV infection in Africa is driven mostly by 
        sexual transmission. The prevention of sexually transmitted HIV 
        through promotion of abstinence (delay of sexual debut) and 
        fidelity (partner reduction) is promoted by the Catholic Church 
        and other religious health providers. Current PEPFAR 
        legislation specifically allocates funds for abstinence and 
        behavior change as part of wider ABC approach. As a result, CRS 
        and other religious organizations have been able to expand 
        their prevention programs. Prior to PEPFAR virtually no funding 
        for abstinence and faithfulness was available.
     There is widespread consensus among public health experts that 
        fidelity and abstinence are necessary components of any 
        comprehensive approach to reduce the spread of AIDS. Evidence 
        has shown that condoms alone are insufficient for a generalized 
        epidemic.\4\ According to the Centers for Disease Control and 
        Prevention (CDC), the surest way to avoid transmission of HIV 
        is to abstain from sexual intercourse, or to be in a long-term 
        mutually monogamous relationship with a partner who is known to 
        be uninfected. For persons whose sexual behaviors place them at 
        risk for HIV, correct and consistent use of latex condoms can 
        reduce the risk of HIV transmission. No protective method is 
        100 percent effective, however, and condom use cannot guarantee 
        absolute protection against any STI, including HIV. In order to 
        achieve the protective effect of condoms, they must be used 
        correctly and consistently.
    \4\ Halperin DT, Epstein H., ``Concurrent Sexual Partnerships Help 
to Explain Africa's High HIV Prevalence: Implications for Prevention.'' 
The Lancet 2004; 363: 4-6.
     Partner reduction is considered to have been the single greatest 
        factor in reducing HIV prevalence in Uganda,\5\ with an 
        estimated 65 percent decline in the number of people reporting 
        nonregular partners between 1989 and 1995.\6\ Data show that 
        the majority of Africans already practice A or B behaviors and 
        that these behaviors are thus realistic for most people. In 
        African countries for which Demographic and Health Surveys were 
        available, an average of 77 percent of men and 97 percent of 
        women ages 15 to 49 had 0 or 1 sexual partners in the past 
        year; and 59 percent of unmarried young men and 68 percent of 
        unmarried young women ages 15 to 24 were abstinent in the past 
    \5\ Green, E. 2003. Testimony at Harvard University before the 
African Subcommittee, U.S. Senate.
    \6\ Low-Beer, D. and R. Stoneburner. 2003. ``Behavior and 
Communication Change in Reducing HIV: Is Uganda Unique?'' African 
Journal of AIDS Research. 2: 9-12.
    \7\ Demographic and Health Surveys. Available at 
     The promotion of abstinence-until-marriage and mutual fidelity 
        within marriage has long been the cornerstone of CRS' HIV 
        prevention programming. Abstinence and mutual fidelity 
        reinforce the precise values and norms necessary for mobilizing 
        people to avoid risk, and for reversing the epidemic.\8\ In 
        short, these approaches work and work well. Without designated 
        funding these excellent programs will be under-resourced and 
        the high quality faith-based health structures and services in 
        PEPFAR countries will be sidelined in the battle against HIV.
    \8\ CRS. 2004. ``AB Narrative Final for PEPFAR AB Grant.'' 

   Certain Add-on Services: We are similarly very concerned 
        about efforts to define ``comprehensive services'' for HIV-
        positive women as necessarily including family planning and 
        reproductive health services. CRS regrets these efforts and 
        asks that such proposals be rejected. Moral tenets of religious 
        organizations like Catholic Relief Services prevent them from 
        offering these ``comprehensive services.'' Our experience is 
        that high quality care, treatment, and prevention can be 
        provided without these additional services. If these services 
        were mandated or given preferential treatment in awarding 
        PEPFAR funds, then Catholic Relief Services and other religious 
        implementers would be unable to participate in PEPFAR. Patients 
        served through our networks, especially in the poorest, most 
        remote areas of the globe, would face interrupted therapy or 
        even cessation of life-saving therapy for lack of qualified 

   Lack of Nutrition and Food Security: Lack of food--or the 
        money to buy it--is the No. 1 concern expressed by ART 
        patients, OVC and their households. All aspects of food 
        security are exacerbated by high rates of HIV and AIDS. The 
        chronic and debilitating progression from HIV infection to 
        full-blown AIDS, accompanied by loss of work and income while 
        seeking treatment lead to poor nutrition, lack of food, hunger 
        and food insecurity. Women and children are disproportionately 
     The low nutritional status of many ART patients compromises the 
        effectiveness of their medications. To fully benefit from ARVs, 
        many patients need therapeutic feeding for a limited period of 
        time. PEPFAR provides funding through USAID for therapeutic 
        feeding, through a pilot program called ``Food by 
        Prescription.'' The program has very clear biometric indicators 
        for determining patient eligibility. However, this program is 
        not available to all due to insufficient funding. Expansion of 
        ``Food by Prescription'' to all PEPFAR countries providing ART, 
        with commensurate increased funding, is desperately needed.
     The majority of CRS' 250 HIV and AIDS projects that target food-
        insecure people living with HIV as well OVC, include an 
        integrated food element. Where possible, CRS partners with 
        USAID Title II Food for Peace (FFP) and the World Food Program 
        (WFP) to provide necessary food and nutrition. Where public 
        resources are not available, CRS uses private resources to meet 
        this need. In addition, CRS supports increased funding for 
        nutrition support in ART programs. Congress needs to evaluate 
        on a priority basis with the Office of the Global Aids 
        Coordinator (OGAC) and USAID the requirements for additional 
        food aid resources.

   Health Care Workforce: Care and treatment involves complex 
        interventions that can either strengthen or weaken the health 
        care systems in PEPFAR countries. The pandemic has greatly 
        stretched the existing health care workforce, especially 
        professionals--doctors, nurses, and pharmacists. Many 
        AIDSRelief local partner treatment facilities will soon be 
        unable to serve additional clients because of the lack of 
        trained staff. PEPFAR needs to provide additional resources to 
        increase the number of health care professionals, appropriately 
        train for task shifting of care and treatment, as well as 
        provide for training, supervision, and remuneration of other 
        nonprofessional community and volunteer health care workers

   Commitment to Meeting Pediatric ART Targets: HIV is eroding 
        gains made in child survival. Mortality and morbidity is high: 
        50 percent of HIV infected children below 2 years of age die 
        without care and ART. In order to improve the outcome of 
        pediatric HIV infection, programs that address prevention of 
        maternal to child transmission (PMTCT) need to be strengthened 
        and a definitive diagnosis of HIV-exposed infants needs to be 
        made as soon after birth as possible. Moreover, health care 
        professionals will require additional training in order to 
        provide care and treatment for infected children and care; 
        pediatric ARV formulations are not readily available, and 
        affordable pediatric treatment programs need to be put into 
     PEPFAR is results-driven and implementers of antiretroviral 
        therapy (ART) projects are evaluated based on their ability to 
        deliver ART to specific targets--10-15 percent for pediatric 
        ART. Achieving this target is challenging for a number of 
        reasons. Pediatric ART dosing according to complicated regimens 
        based on changing age, weight, and height of growing children 
        is very challenging. Also, pediatric formulations are more 
        expensive than ART regimens for adults. Implementers are more 
        likely to initiate adults on ART because it is easier and 
        cheaper and thus they are more likely to achieve their ``number 
        of people on ART'' targets.
     If PEPFAR implementers are to meet or exceed a 10-percent 
        pediatric ART goal, as they should, they will need targeted 

   High Numbers of Orphans and Vulnerable Children: Older 
        children in AIDS-affected households are often forced to quit 
        school because of deteriorating family finances and/or because 
        they need to care for their ailing parent. A most disturbing 
        phenomenon is the reality of young girls forced into 
        transgenerational sex to meet their own and their family's food 
        needs. Younger children of school age often never even start 
        school. Those lucky enough to attend school often don't have 
        enough to eat. Linkages with WFP in Tanzania and USAID FFP in 
        Kenya and Haiti enable us to provide critical nutritional 
        support for these children. As Congress reconsiders PEPFAR 
        reauthorization, there is an urgent need for increased funding 
        for OVC support as well as a requirement to systematically link 
        PEPFAR programming with food programming. Unfortunately, in 
        other countries, rigid regulations, program requirements, or 
        other bureaucratic problems have made it impossible to link 
        PEPFAR OVC support with other funding for nutrition, education, 
        or other critical needs.
     As Congress reconsiders PEPFAR reauthorization, there is an urgent 
        need for increased funding for OVC support as well as a 
        requirement to systematically link PEPFAR programming with 
        food, education, and other programming.

   Complicated PEPFAR Funding Mechanism: The number of USG 
        agencies involved in PEPFAR, the multiple levels of programming 
        and budget consultation, decisionmaking, and grant management 
        procedures (Central and Mission-level), and the number of 
        countries involved, all contribute to increased costs and 
        complicated/cumbersome reporting, cash disbursement, and 
        decisionmaking. The CRS-led AIDSRelief ART project is a 
        centrally awarded 5-year cooperative agreement through HRSA, 
        but administered in the field by both CDC and USAID. Since year 
        2, a static portion of AIDSRelief funding continues to be 
        obligated centrally through HRSA, while another increasingly 
        larger portion is awarded each year through the Country 
        Operating Plan (COP) at the local USG mission. The onerous COP 
        process combined with late obligation of funds causes 
        particular challenges for implementing partners in the field 10 
        months of the year.
     Furthermore, since we cannot predict out-year resources in the 
        context of the current ``annually renewable commitment'' COP 
        funding mechanism, long-term planning is extremely difficult. 
        This affects the confidence of our partner sites to continue 
        expanding their activities to meet their targets. As a result, 
        many sites have taken a very conservative approach to scale-up 
        due to fears that funding will be reduced or cut, and will 
        result in the sites themselves needing to bear ongoing 
        treatment costs--which most cannot afford.
     PEPFAR needs to institute multiyear funding for multiyear awards; 
        strengthen the centralized funding mechanism; change the 
        funding cycle to correspond to the fiscal year, and streamline/
        standardize the COP process.

   The Global Fund: Through Round 7, only 5-6 percent of the 
        total funding channeled through the Prime Recipients (PR) of 
        the Global Fund for AIDS, TB and Malaria (GF) were faith-based 
        organizations. Even including subrecipients of Government or 
        secular prime recipients, less than 15 percent of GF-support 
        programs are faith-based organizations.\9\ The nascent ``dual 
        track'' financing mechanism hopes to put civil society on equal 
        footing with national governments in the country coordinating 
        mechanism (CCM)--Churches Health Association of Zambia is a 
        poster-child for this innovation. However, the idea of pairing 
        an NGO principal recipient with a government one is only a 
        recommendation by GF to national CCMs. Religious health care 
        providers account for 30-50 percent of health care services 
        done in many developing countries--up to 70 percent in some 
        countries.\10\ Many religious health care providers report that 
        they do not have access to the CCMs to help plan and achieve 
        the national plan responding to AIDS, TB, and malaria. The huge 
        potential of religious health care providers is not being 
        adequately recognized and engaged in the fight. Since the U.S. 
        Government is providing one-third of the resources for the 
        Global Fund, Congress should take steps to make sure that local 
        religious health care providers are meaningfully engaged in 
        their countries' CCM and adequately resourced to participate in 
        achieving their countries' national plan. This will insure the 
        most productive allocation of scarce resources to achieve the 
        maximum impact possible in terms of lives saved and protected.
    \9\ ``Distribution of Funding After 6 Rounds'' on http://
    \10\ African Religious Health Assets Programme. 2006. 
``Appreciating Assets: The Contribution of Religion to Universal Access 
in Africa.'' Report for the World Health Organization. Cape Town: 
ARHAP, October 2006.

    Finally, CRS strongly supports increased funding for PEPFAR--above 
$30 billion. The program, however, must maintain its focus on HIV, 
malaria, and TB and should not be expected to fund the many other 
related development needs that poor HIV-affected communities have. 
Similarly, an expanded PEPFAR must not come at the expense of urgently 
needed increases in other core poverty development accounts, including 
Child Survival, Title II Food for Peace, agriculture, and microfinance.
    I would like to once again express my appreciation to Chairman 
Menendez, Ranking Member Lugar, and all the members of the committee 
for calling this hearing to discuss the next phase of this highly 
successful program. We urge timely reauthorization for this initiative 
that preserves the best and most effective elements of this program 
that is so vital for the health of some of the world's poorest and most 
vulnerable people. We and our partners stand ready to continue and 
expand the lifesaving work that PEPFAR has enabled us to accomplish. I 
would be happy to respond to any questions the committee may have.

                               TABLE 1.--CRS-LED AIDSRELIEF ART PATIENT ENROLLMENT
                                          [As of October 31, 2007] 1,2
                                                                                       % of total
                                                                     Current # of    PEPFAR-funded
                                                       Current #      Pediatric       ART patients    Cumulative
                 Country                   Current #  of Patients   Patients (<15       who are          # of
                                           of LPTFs*     on ART     years old) on       enrolled     Patients in
                                                                      ART (% of         through          Care
                                                                        total)        AIDSRelief**
Guyana...................................      3            524          47 (9.0%)           22            1,462
Haiti....................................      8          2,347        479 (20.4%)           18            7,471
Kenya....................................     20         17,795      1,808 (10.2%)           11           38,499
Nigeria..................................     22         11,706         492 (4.2%)           10           31,819
Rwanda...................................     13          1,553        155 (10.0%)            5            3,174
Shared w/MAP.............................      5          1,018          76 (7.5%)           --            3,126
South Africa.............................     26         12,900       1,092 (8.5%)            6           30,523
Tanzania.................................     31         13,825         993 (7.2%)           16           35,993
Uganda...................................     16         13,788       1,037 (7.5%)           17           49,133
Zambia...................................     14         15,407         990 (6.4%)           11           35,242
      Total..............................    153         90,638       7,169 (7.9%)           11          233,699
\1\ ``World AIDS Day 2007: The Power of Partnerships,'' Factsheet. PEPFAR, U.S. Government, December 1, 2007,
  available at: http://www.pepfar.gov/documents/organization/96070.pdf.
\2\ ``HRSA Monthly Report, October 2007.''
* LPTF = Local Partner Treatment Facility.
** This column calculated based on September 30, 2007, PEPFAR and AIDSRelief data.
*** This is also the total percent of patients on ART in Kenya.

    Senator Menendez. Thank you, Mr. Hackett.
    Thank you all for very insightful testimony.
    We'll start with 5-minute rounds, and I think we'll have 
time before the first round of votes take place on the floor. 
The Chair will recognize himself.
    Dr. Kazatchkine, the Global Fund and PEPFAR seem to appear 
most successful when they are able to coordinate their 
activities. What countries offer the best examples of that 
coordination? And what are those best practices being followed 
by others?
    Dr. Kazatchkine. Thank you. Yes, indeed. Countries where 
both PEPFAR and Global Fund are strongly coordinating are 
making very rapid and impressive--particularly rapid and 
impressive progress.
    Let me cite Ethiopia, where PEPFAR and Global Fund have 
been coordinating their efforts with regard to HIV/AIDS under 
the leadership of the Minister of Health. We work together so 
that either first-line treatment--what we call first-line 
treatment; that is, the first treatment that is prescribed to 
patients--or second-line treatment, the treatment that is 
prescribed to patients who have become resistant to first-line 
treatment, are financed either by one or the other source, 
either PEPFAR or Global Fund, depending on what's more 
appropriate and easily available.
    We have aligned, both of us, PEPFAR and Global Fund, on the 
national strategy, as established by the Ethiopian Government. 
The Ethiopian Government is in leadership. And that has led to 
spectacular increases in the number of people treated in 
    This is--the same is happening in Kenya, in Cote d'Ivoire. 
I have been traveling to Cote d'Ivoire recently, together with 
Ambassador Dybul. We have also been to Rwanda, to Haiti. 
Wherever we go, our message is: We're working hand in hand, 
    Senator Menendez. Are there a series of best practices that 
    Dr. Kazatchkine. Country best practices? Yes.
    Senator Menendez [continuing]. Are trying to promote with 
    Dr. Kazatchkine. Yes, indeed; particularly with regard to 
antiretroviral therapy, modalities of prescribing and 
distributing antiretroviral therapy. And, in fact, I think that 
it now, basically, in the 15 focus countries of PEPFAR, these 
practices--best practices are being implemented.
    Senator Menendez. Let me ask both Dr. Smits and any others 
who want to address this, I read the recent report by the 
Global HIV Prevention Working Group, which, in its report 
entitled ``Bringing HIV Prevention to Scale, an Urgent Global 
Priority,'' opened up with, ``We should be winning in HIV 
prevention. There are effective means to prevent every mode of 
transmission. Political commitment has never been stronger. 
Financing for HIV programs in low- or middle-income countries 
increased sixfold between 2001 and 2006. However, while 
attention to the epidemic, particularly for treatment access, 
has increased in recent years, the effort to reduce HIV 
incidence is faltering.'' And I know some of you touched upon 
    I'd like to know what we and the rest of the world should 
be doing more aggressively on the question of prevention and 
what are we doing well, and what are we not doing that we 
should be doing in this regard? There are promising 
technologies, such as male--medical male circumcision. I'd like 
to hear what we should be doing on the prevention side that we 
are not.
    I'll start with you, Dr. Smits, and any others who want to 
address it.
    Dr. Smits. First, I wouldn't be--personally, and I think 
the committee--would not be as negative as that statement 
appears to be. Certainly, the new U.N. numbers suggest very 
strongly that, in some countries, we're really moving ahead on 
prevention. But we need to do a great deal more in terms of 
very precise evaluation of what's happening. We ought to be--
we're--in a sense, we're waiting, now, to see the epidemic 
change in order to figure out whether the behavior changes 
we're teaching are really making a difference. I think we can 
look more carefully at behavior changes with targeted surveys.
    I was privileged to go to the implementers meeting last 
June, and I heard several very good talks, particularly one by 
David Apuli, who is the head of the program in Uganda, who says 
that the way to fight AIDS is to know where your last thousand 
cases came from, and to target your prevention efforts there so 
that you don't keep doing what you were doing very successfully 
2 years ago. I think there's a risk of that. He particularly 
emphasized the discordant couples and the need to develop 
different messages for them, not just condom distribution, but 
a lot more counseling in the treatment and care settings with 
someone known to be HIV positive, about what the implication is 
for their partner.
    I think that message--What were the last thousand cases, 
and how can we best attack them?--is really the most useful.
    So, I don't think we can tell people in these countries how 
to do their programs. I think that they know a great deal about 
it. We need to give them the flexibility, and we need to give 
them the scientific support to look at the results of what 
they're trying to do.
    Senator Menendez. Dr. Daulaire.
    Dr. Daulaire. Thank you, Mr. Chairman.
    I would concur. I think there is starting to be good 
evidence that the tide is beginning to be turned. Certainly, in 
some places like Thailand and Uganda, there has been 
substantial impact from prevention activities. And what's 
striking there is how very different the prevention activities 
that those two countries undertook were. In Uganda, as my 
friend Ken Hackett has pointed out, the issues of partner 
reduction, faithfulness, abstinence have been very important 
components. In Thailand, the issue of condoms was much more 
important, and that was because the dynamics of the epidemic 
were very different in the two places.
    Clearly, in order to turn--really turn the tide, in terms 
of prevention, recognizing that AIDS is, fundamentally, an 
asymmetric kind of disease, it doesn't spread the same way 
everywhere, it really depends on different populations, 
different routes of transmission. What is most important is 
making prevention, the reduction of new infections of HIV, a 
priority--a stated priority, that has to be measured, that has 
to be tracked and followed. And those new infections, 
particularly, should be focused on those most likely to 
continue the chain of transmission, because, when you're 
looking at the numbers over time, that's where successful 
interventions can have the biggest impact.
    So, I don't believe that a prescription is called for here, 
in terms of the new legislation, in terms of ``do this or that 
at these percentages,'' but I do believe that prevention should 
be clearly prioritized. I think the first Leadership Act 
rightfully focused on treatment, because there was virtually no 
treatment in the world. And I think there is good justification 
for its focus on abstinence, because that was a neglected part 
of the equation. I think the world, and the world of 
implementation, has changed a great deal since that time.
    Senator Menendez. Thank you.
    I'd love to hear from all of you, but I need to get to 
Senator Lugar, so maybe in the next round I can hear some of 
your further answers on this.
    Senator Lugar.
    Senator Lugar. Thank you very much, Mr. Chairman.
    Dr. Kazatchkine, I appreciated your thoughts about 
transparency and accountability. These are virtues that are 
shared by the Congress, and our oversight, really, is dedicated 
to this. I just want to, more specifically, inquire about the 
Global Fund's ability to attract the most effective, efficient 
contracts for medicines and services at the lowest possible 
prices. What are your largest contracts, and how do you go 
about bringing about transparency, accountability, and auditing 
of those contracts?
    Dr. Kazatchkine. Yes; we have a number of mechanisms in 
place in order to ensure transparency and accountability.
    First, we do have portfolio managers in the secretariat at 
the Global Fund that track every single grant throughout the 
grant cycle, from grant signing to implementation, and follow, 
from our Geneva office, everything that happens during the 
grant cycle.
    On the ground in countries, the--what we call the country 
coordinating mechanism, which is a collective group of 
stakeholders, government, civil society, multilaterals, 
bilaterals--the U.S. Embassy or USAID is usually represented in 
most of our CCMs--are--have, also in their functions, to 
provide oversight on the country program.
    And then, at the country level, we have an independent 
observer with whom we subcontract, which we call the local 
funding agent, and that local funding agent reports to us every 
3 months, or sometimes, when necessary, more often, on both the 
financial aspects of the grant, the disbursements, but also on 
the programmatic results and how those match.
    Whenever something appears going wrong, we call the--we 
trigger--this triggers what we call an early alert response 
system, and, if necessary, we call on an outside investigation 
or we call on an audit by the inspector general from the Global 
Fund. That inspector general this year, as you know, has been 
the inspector general of WHO, as an interim inspector general, 
from January this next year, a new inspector general has now 
been appointed, John Parsons, who, until now, has been the 
inspector general of UNESCO.
    Senator Lugar. Why, thank you very much for that testimony.
    I have a second question with regard to China and its 
participation. I understand that China is a member of the 
board. It makes a contribution to the Global Fund. But, at 
least our information is, it receives from the Global Fund a 
very large multiple of that amount of money for various 
reasons. Do you follow that? With the insight of what China may 
be able to do for itself in due course; that is, replace those 
particular services and funds now that are received from the 
Fund, as there may be others who are in much more difficult 
financial condition, given the practicalities of world growth, 
Chinese growth, and so forth. Can you make a comment about the 
Chinese situation?
    Dr. Kazatchkine. Yes. Thank you.
    I see two aspects to your question. One is the specific 
issue of China, the other is funding, by Global Fund, of grants 
in-country with, let's say, rapidly emerging economies, and 
that, in addition to China, is also India and Russia.
    Now, the Global Fund has played a key role in triggering 
access to prevention and to treatment of HIV in China. We are, 
indeed--have a very large portfolio of grants there, over 400 
million U.S. dollars. If there had not been the Global Fund, we 
wouldn't have seen prevention among IV-drug users that are one 
of the drivers of the epidemic, particularly in southern China, 
we wouldn't have seen developed the efforts of prevention among 
truck drivers and among some of the vulnerable populations that 
are reached by our funding through civil society.
    I do agree with you that, following that first phase, it is 
time for China, progressively, as it is for emerging countries, 
not to only be a recipient, but also become a larger donor to 
the Global fund.
    Now, Russia has just given an example. Russia, that has 
received $270 million from the Global Fund, and where the 
Global Fund has also been a key trigger of access to services 
for vulnerable populations, has decided, last year, to 
reimburse, actually, every single donor dollar that it has 
received from the Global Fund by 2010, and they came to our 
recent replenishment conference with signing a first check of 
70 million U.S. dollars.
    I do hope that China and India will progressively follow 
that example. And my advocacy with these countries--I'll be in 
India next week--is to ask them to provide a percent of their 
annual increase in wealth for global health.
    Senator Lugar. Very good news.
    Thank you very much, sir.
    Senator Menendez. Thank you.
    Senator Kerry.
    Senator Kerry. Mr. Chairman, thank you. And thank you very 
much for having this important hearing.
    Obviously, dealing with this issue is not a partisan issue, 
as the record of this committee well displays. As we know, over 
90 percent of all the children infected with HIV live in 
Africa, so that's 2 million out of the 2.3 million kids that we 
know are affected. And 1,800 more become infected every single 
day. And more individuals are becoming infected than are being 
treated, which is the challenge, obviously.
    I just came back from South Africa and Botswana, and got an 
up-close-and-personal reminder of how devastating it is, and 
the threat that it poses to an entire continent's stability. I 
had the privilege of visiting the Umgeni primary school and 
talking with people in Kwankalosi and Kwazulu-Natal, near 
Durban, and I saw very inspiring, but, at the same time, 
heartbreaking situations. I remember one woman in a mud hut, 
tiny mud hut, cooking some--with a caregiver, a caregiver who 
was trying to help her, comes once a week. She has three kids. 
They are in school. Her sister has already died of the disease. 
And it just--you know, you can just extrapolate that, you know, 
thousands upon thousands of times. I was inspired by the work 
of the Valley Trust caregivers, but I also met orphans who, at 
a young age, have become the caretakers of their whole family, 
assuming adult responsibilities. And, again and again, I heard, 
from those on the front lines of this pandemic, that their 
greatest challenges is the public-relations battle to educate 
their communities.
    I was struck, also, in a session that I had with some of 
those folks responsible for educating and caregiving, as I 
tried to elicit from them the figures. Because there was some 
press around, and some other public people, they just were very 
clammed up. They wouldn't want to talk about it. They were 
fearful of retribution for telling the truth about what's going 
on. And, privately, they pulled me aside later and, sort of, 
told me why they were fearful and couldn't tell me, sort of, 
the real numbers of kids in the school. I asked, How many kids 
here? In fact, they're--how many kids are orphans--and so 
    We have to work incredibly hard. And we all know the 
problem that existed with President Mbeke and the government 
itself in South Africa in getting this truth out. But it 
reaffirmed for me the fact that, while AIDS has done the 
killing, the disease's best allies have been denial, 
indifference, and ignorance. And that's what we have to, sort 
of, fight here, partly, in whatever we structure here as the 
    Let me also nitpick for a tiny moment, if I may, on a 
personal level. As I was walking out of one of those locations, 
I saw this poster up on the wall, and it said, ``The 
President's Emergency Program.'' And it, sort of, hit me, to be 
honest with you. I said, ``What do you mean, the President's? 
First of all, which President?'' But, second, that legislation 
was written right here in this committee by Bill Frist and 
myself, and Jesse Helms joined into writing that. Remember, 
Senator Lugar? And Senator Lugar and others put that together. 
And it's not the President's, it's the American people's, it's 
the United States, and it would do us a lot more good, frankly, 
if more people knew what the United States of America is doing, 
and what the American people are doing, with respect to this. 
And so, Mr. Chairman and Mr. Ranking Member, I hope when we 
redo this, we're going to clarify that. I think that's 
important as a matter of policy.
    Equally importantly, if I may say, that--you know, we did 
that in 2002, and we proposed the futures of $15 billion; and 
so--but we're delighted the President came and picked it up, 
and we're delighted, without his leadership and involvement--
obviously we wouldn't, probably, have gotten the money, in the 
end. But I think we ought to, sort of, see this for what it is, 
in its reality.
    But what I want to focus on with the panel that's here 
right now as we think about this is, sort of--we're all aware 
of the 2-7-10 goal for 2008. My fear is that, unless we can 
break through more effectively on this education--my daughter, 
incidentally, went over for a summer as a medical student; 
she's now an intern. But she went to Ghana, and she went to 
Rwanda, and she worked in AIDS for the entire summer. And she 
wrote her paper--her graduate paper on the truck routes and how 
that is. You were speaking, Dr. Smits, about knowing where the 
last thousand cases is. Well, that's where the last--how many--
tens of thousands of cases have come through, is the truck 
routes, and obviously there are other causes. But it seems to 
me that there has to be a much more intensive focus on 
coordinating the prevention, slash, education breakdown and 
mythology, and engagement of the governments themselves. I 
mean, the leaders have got to go out there and have these 
tests, not just guests. And they've got to do it regularly. And 
they've got to really prove the importance of this. And, 
otherwise, these dollars are just, kind of, going to go 
incessantly at this increasing population of people that we're 
not treating. And, you know, I don't think we want to make this 
like Sisyphus pushing the rock up the hill, if we don't have 
to. And I don't think we have to. So, my hope is that we could 
do that.
    One of the things I heard at the University at 
Witzwatersrand, where we met with public health folks, was 
their concern about PEPFAR being a separate track, completely, 
and not integrated enough into the rest of the health care 
delivery system. Now, to some degree, when you started up, that 
may have been necessary. But, at this point in time, it strikes 
me, we may want to try to create a greater integration. So, I 
wonder if you'd just take a moment--I've exceeded my time in 
questioning--just ask the one question: What do each of you 
see, in terms of that potential of integration, and how do we 
frame this better to deal with this ad infinitum added 
population and break down the mythology and get greater 
accountability in these countries?
    Dr. Kazatchkine, do you want to start? And then we'll go 
right down the line.
    Dr. Kazatchkine. Yes; I'll--very briefly. And then, Mr. 
Chairman, I regret, but I'll ask the committee's permission 
that I leave; I have to fly back to Geneva right this 
    Thank you for your question, Senator Kerry. Right before 
you came in, I had a question from Senator Menendez on 
integration between PEPFAR and the Global Fund. Actually, in 
countries where PEPFAR and Global Fund are both present--that 
is, in fact, in the 15 focus countries--there is a very strong 
integration of both programs around the national priorities. 
The Global Fund itself that is in the other countries--and 
we're currently funding grants in 137 countries around the 
world--is, as I discussed in my remarks, a country-owned 
mechanism. We're funding what the countries request us to fund. 
So, in fact, we do align, by definition, on the national 
program. So, there is full integration of Global Fund grants 
with national programs. And we're currently moving into, as I 
also very briefly discussed in my remarks, going to fund 
national strategies, rather than pieces of national strategies, 
in the future.
    Senator Kerry. Dr. Smits.
    Dr. Smits. I only did--the committee visited in small 
groups, so I only visited----
    Senator Menendez. Before you continue, Dr. Smits--
    Doctor, we're going to excuse you. We were told that you 
had a flight. We appreciate your testimony. There may be 
questions submitted for the record, that we'd ask you to 
respond to, subsequently. And have a safe journey.
    Dr. Kazatchkine. I will be pleased to. Thank you very much.
    Senator Menendez. Thank you.
    Dr. Kazatchkine. I'm sorry.
    Senator Menendez. Dr. Smits.
    Dr. Smits. I only visited three countries on a formal 
basis, but I would say that the degree of coordination that I 
saw in all of those was really quite good, and the response of 
PEPFAR to government priorities was very good. For example, in 
one, the ministry responsible for orphans said, ``It's so 
wonderful to have you here. We've had all these plans for these 
programs, and PEPFAR's commitment to orphans will make a huge 
difference. And I want you to promise to come back in 2 years 
and see how much we've accomplished, because I'm just starting 
    In another country, we visited with the Ministry of 
Defense, which is doing some very exciting things. As you know, 
African countries with a strong military earn money by sending 
their soldiers into other countries on peacekeeping missions, 
and must send them out HIV negative, and protect them when 
they're away. And they've done a marvelous job. That ministry 
told us that they believed that PEPFAR was the result of divine 
intervention. I thought maybe the Congress would have something 
to do with it. But that sense that we had come----
    Senator Kerry. We are very divine these days. [Laughter.]
    Dr. Smits. We had come and brought resources to something 
they wanted to do, and they had planned, that was important to 
them on a national basis. So--and we certainly saw a number of 
examples, the other team members did, in many of the countries, 
very close coordination with the Global Fund. It's a bit 
variable, country by country. A lot has to do with how strong 
the country leadership is. But I think you can't dictate it. 
You can say it's very important, but you can't say how to do 
it. But I think it really is happening.
    Senator Menendez. Thank you.
    Senator Feingold.
    Senator Feingold. When I was in Uganda recently, I met with 
key representatives from the HIV/AIDS community, and we 
discussed the importance of building national capacity so that 
these countries will be increasingly able to meet the health 
needs of their own citizens. But some of the health experts 
have argued that international HIV/AIDS programs might worsen 
overall health in developing countries because of the 
phenomenon of local health workers being attracted to the 
United States and multilateral initiatives that provide higher 
compensation and benefits than those offered by public health 
centers. This migration of HIV/AIDS programs could also leave 
fewer health workers available to treat people suffering from 
other health complications. Do you think this is a valid 
criticism and concern?
    Dr. Daulaire. Let me start, Senator Feingold. It is a valid 
concern. We are seeing, all over sub-Saharan Africa, the 
migration of health care workers; in some cases, from Africa to 
more affluent countries--brain drain--because of better 
salaries; in some cases, moving from low-paid government jobs 
in clinics doing maternal and child health services into HIV/
AIDS programs. This is not to argue that we shouldn't be doing 
these things, and that we shouldn't be funding them, but it 
certainly is a clear argument that health workforce development 
and support, as part of a broader approach to health systems 
strengthening and development, is critical.
    Ultimately, at the end of the line, the person who 
administers the antiretroviral therapy, who does the health 
education for prevention, is the same person who takes care of 
the mother during her pregnancy, who takes care of the child 
when the child gets ill with pneumonia or diarrhea, the HIV-
negative child. And unless we work to strengthen the 
integration of the HIV programs into the broader primary health 
care system, we're going to be at risk of turning this into a 
two-track system which could have negative consequences for 
    Senator Feingold. Sure.
    Mr. Hackett. If I could just add to that with a specific 
example, because I agree with Nils.
    Recently--well, 3 months ago, in Kenya, the Catholic 
bishops made an appeal to the President; a personal appeal. 
They were losing most of their good staff from the Catholic 
hospitals, which represent a sizable portion of health care in 
Kenya, and they were losing them to those government programs 
that got a recent grant, both from the Global Fund and UNAIDS. 
I think we would all agree, here, that there has to be a better 
coordination of all kinds of approaches, both programs, in a 
national sense, and also local programs.
    For instance, we, the U.S. Government, directly and through 
the World Food Program and through agencies like mine, provide 
food assistance, sometimes, in the country, or money for 
agricultural activity. It is not generally coordinated with the 
AIDS program, so that those people that you met in South 
Africa, those young orphaned kids, one of their worries is 
where they're going to get a meal. And we could do a much 
better job in integrating services. What about the woman who 
has gone through the antiretroviral therapy, comes out of the 
hospital. She's sold everything--pots, pan, tin roof. She's got 
nothing. What she needs is a way to start her life again.
    Senator Feingold. Well, how do we make sure that another 
aspect of the United States or the NGOs that we contract with 
do not actually hire away these scarce professionals who do the 
AIDS work? How do we deal with that?
    Dr. Daulaire. I think a question, Senator, is you're 
dealing with a finite resource, and if we focus on putting a 
cap on that relatively small bottle of trained health care 
providers, I don't think that's going to resolve the problem, 
because the bottom line is, there is a huge deficit of health 
care workers in these countries to begin with. We have to be 
intimately involved, along with our partners, along with the 
host countries, in supporting the development and training of a 
much larger cadre of health care providers, not primarily 
doctors, I would say, because they are the most fluid of all--
they migrate like crazy--but nurses, paramedics, people who are 
actively involved in community health in their own communities, 
and who can be trained to do 95 percent of what needs to be 
done, in terms of HIV care and the other aspects of primary 
health care. So, training, deployment, management, and support 
are critical here.
    Senator Feingold. Thank you, Mr. Chairman.
    Senator Menendez. Senator Lugar.
    Senator Lugar. Thank you, Mr. Chairman.
    I just wanted to ask Mr. Hackett, as someone in the field 
to respond to this. We have premised this hearing, the one we 
had before, and early introduction of legislation, on this 
basis that other countries and other contributors need to have 
assurance that we are going to have continuity of our support. 
As all of us have witnessed our appropriation process this 
year, we're coming into the final days of calendar year with 11 
of our 13 bills not passed, and this is noted by other 
countries. They understand that we're going to be there for 
them in due course, but have been raising questions, in terms 
of the continuity of support, and therefore, what they are 
likely to contribute in the process. Now, they can go ahead 
without us. But, as we are a leader and a large contributor, we 
think, at least, that this is very important.
    I would just like a confirmation statement from you, or 
other members of the panel, as to the importance of the 
timeliness of action, as opposed to the fact that, evenutally, 
it will happen but maybe after many lives have been lost if 
there is a break in service.
    Mr. Hackett. Senator, I couldn't emphasize more that the 
message you are sending is heard. And if there is a swift and 
robust action to authorize the second PEPFAR at a level that 
we're talking about, either at the higher level, or even at the 
$30 billion level, that will be heard, and it will send, to the 
richer nations, a clear message that they must step up to the 
plate. And I think--it was said earlier, those people, our 
partners that we work with, want to know that there is a 
future. They've started people on antiretroviral treatment. 
Those people are alive. They want to keep them alive. So, they 
want to be sure about this. And there are many millions of 
people affected.
    Senator Lugar. Thank you very much.
    Dr. Daulaire. Senator, if I may, it is critical to get this 
done over the next several months. Particularly concerning 
antiretroviral treatment, if we get a break in the chain of 
treatment of people who are already under care, we are at risk 
of building a cataclysm, in terms of drug-resistant HIV, so 
we're no longer dealing with infections that are susceptible to 
the first line of treatment. It is vital that this program be 
reauthorized and refunded quickly.
    Senator Lugar. Yes.
    Dr. Smits. Can I just add? First of all, to second that, 
one of the accomplishments of PEPFAR is that we have not yet 
experienced any major disruption in drug availability, and we 
need to keep up that record. But many of the people doing the 
implementation of all aspects of the programs are employees of 
NGOs in these countries; and if the program is not reauthorized 
in a timely manner, those NGOs may have legal obligations to 
begin issuing layoff notices. So, it's really critical, in 
terms of moving forward, to have early reauthorization--I know 
you know that, but I--at least I can say it for the record.
    Senator Lugar. Well, this is important testimony. I know 
that the chairman has been working with Senator Kennedy, who is 
very instrumental, at the HELP committee. We all have at stake, 
and we're attempting to do our part.
    I am encouraged by Dr. Kazatchkine's comments about the 
Russian contribution and this whole premise that many countries 
now, surprisingly, have economies that are growing, and growing 
rapidly. There is substantial new wealth and ability to step up 
to the plate, in terms of world responsibility, as opposed to 
being, necessarily, recipients. It could very well be the 
timeliness of our action that would be helpful as he works with 
members of his board, who may now be able to turn large 
recipients to substantial contributors. This is, I think, a 
facet that's arisen from this hearing. This knowledge, at least 
for me, about how others may be taking a look at it, may mean a 
lot in the future in terms of their own contributions.
    Thank you, Mr. Chairman.
    Senator Menendez. Thank you. Thank you, Senator.
    Two last questions before we'll break. And we thank you all 
for the time you've spent with the committee.
    Dr. Smits, one of the central recommendations of the IOM 
report is to the U.S. Global AIDS Initiative to maintain its 
urgency and its intensity, but to shift to a more sustainable 
approach. As we talk about reauthorization, especially--the 
timeliness of it and, the importance of it--the question is, 
presumably, that same recommendation could be extended to the 
Global Fund, as well. How do you believe, for example, that 
PEPFAR and other programs can begin this transition to 
    Dr. Smits. There are many details in the report that move 
that way--longer term planning cycles, total coordination with 
the country coordinating mechanism--and we saw some very good 
examples of that--so that the country is doing the planning, 
and we are supporting it, not us doing the planning and then 
just, sort of, showing them the papers. Then there is the 
support of training programs. I worked in Mozambique several 
years, I know the details of nurse training and clinical 
officer training in Mozambique. It would not be expensive to 
expand those programs. You just need the money to keep the 
schools open. The teachers are paid on a module basis; pay the 
teachers for more modules. You could expand workforce quite 
reasonably. And my understanding is, many other of these 
countries have similar arrangements. Expanding medical schools, 
there, as here, is probably slower and more expensive, but that 
can be done, as well. We need to be a participant in that. Many 
other donors already are. But--so, long-term planning, more 
workforce, and the most efficient use of our dollars, 
particularly by eliminating the separation across prevention, 
treatment, and care.
    Senator Menendez. One last question. A leading killer of 
people with HIV/AIDS is tuberculosis. It is inextricably linked 
to the epidemic. And, given the high rates of TB/HIV co-
infection in the 12 PEPFAR focus countries in Africa, TB 
programs present an opportunity to identify additional HIV-
positive individuals who are eligible for treatment. Similarly, 
the HIV clinics provide an opportunity to screen for TB. PEPFAR 
has been in the process of expanding efforts to combat 
tuberculosis in HIV patients, but we could be doing far more in 
this area. Should addressing TB/HIV by increasing integration 
and coordination among programs be a greater focus in PEPFAR 
    Dr. Daulaire. Yes.
    Senator Menendez. That's about as clear as it gets around 
here, you know. [Laughter.]
    Dr. Daulaire. The----
    Senator Menendez. It's a refreshing answer, but I know you 
want to embellish a little bit on it.
    Dr. Daulaire. Very short. [Laughter.]
    Dr. Daulaire. The reality is that, currently, one-half of 
one percent of people receiving HIV/AIDS care and treatment are 
tested for TB. You've got to look for it before you can start 
doing anything.
    Senator Menendez. Dr. Smits.
    Dr. Smits. I'll also say yes. One of the impressive things 
PEPFAR does is hold the implementers conference every year. 
People working in the field have a lot of very good things to 
say about that conference. The discussion about the TB 
integration made it clear there, that that is an area that has 
lagged. But people are very concerned, and there are some best 
practices being put in place. Yes; I agree it's an important 
    Senator Menendez. Well, seeing no other members before the 
committee, I want to thank all of you for your testimony today. 
It's been incredibly important as we move to what will 
hopefully be a timely reauthorization.
    The record will remain open for 2 days so that committee 
members may submit additional questions to the witnesses. We 
would ask the witnesses respond expeditiously to these 
    Senator Menendez. And, if no one has any additional 
comments, the hearing is adjourned.
    [Whereupon, at 4:05 p.m., the hearing was adjourned.]

              Additional Material Submitted for the Record

 Prepared Statement of Dr. Paul Zeitz, Executive Director, Global AIDS 
                        Alliance, Washington, DC

                                      Global Aids Alliance,
                                 Washington, DC, December 13, 2007.
Hon. Joseph R. Biden,
Chairman, U.S. Senate Committee on Foreign Relations, Dirksen Senate 
        Office Building, Washington, DC.
    Dear Senator Biden: On behalf of the Global AIDS Alliance and the 
Health Gap coalition, I would like to formally request that the 
attached document be submitted as part of the record of the Senate 
Foreign Relations Committee hearing held on December 13, 2007.
    The document details recommendations for the next phase of the U.S. 
global AIDS initiative developed by African civil society organizations 
and people living with HIV/AIDS working on the front lines of the AIDS 
    The Global AIDS Alliance is dedicated to mobilizing compassionate 
and comprehensive response to the global AIDS crisis, and we believe 
that the voices of African civil-society stakeholders--and the 
communities they represent are essential to ensuring that U.S. global 
AIDS policies and programs effectively meet the needs and priorities of 
the people they are meant to serve.
            Sincerely yours,
                                         Dr. Paul S. Zeitz,
                                                Executive Director.


African Civil-Society Recommendations on the Next Phase of U.S. Global 
                   AIDS Assistance--December 11, 2007

    On December 10-11, 2007, representatives of 21 civil-society 
organizations, including representatives of PLHA organizations as well 
as large PEPFAR AIDS treatment providers, met in Nairobi to provide 
feedback and recommendations on the future of U.S. global AIDS policy. 
The meeting was hosted by the Kenyan AIDS Treatment Access Movement, 
Global AIDS Alliance, and Health GAP. In light of the upcoming debates 
on PEPFAR reauthorization, we respectfully submit the following 
recommendations from people living with HIV/AIDS and working on the 
front lines of the AIDS pandemic. The following summarizes our 
prioritized recommendations, and a full report will be made available 
    1. Numbers on treatment versus measuring healthy patients: PEPFAR 
is doing a historic and important job of getting people on ARV 
treatment. However, counting a person who is receiving AIDS drugs is 
not the same as supporting health for people with HIV. The urgent and 
important work of attempting to meet treatment targets is not 
integrated with more comprehensive support for actual patient health. 
When patients are only provided one part of what we need to survive, 
however important, the end result is poor health outcomes, questionable 
accounting practices, and unacceptable loss to follow up.

   The second five years of U.S. global AIDS initiatives should 
        measure longer term patient health outcomes in addition to 
        simple numbers of people on ARV treatment. This should be 
        backed up by independent patient satisfaction surveys and spot 
        audits of PEPFAR-supported medical facilities.

    2. Opportunistic infection drugs are not available: Many programs 
provide free ARVs, which are urgently required and profoundly 
appreciated. However, efforts to scale up access to AIDS treatment is 
taking place without an eye toward actually increasing patient 
survival. While anti-AIDS medicines are almost always free, medicines 
to treat the opportunistic infections that accelerate our death are 
often unavailable from clinics and too costly for patients to purchase 
from pharmacies. Stock-outs at medical facilities and dispensaries are 
also common and very harmful to patient health.

   PEPFAR should provide free and accessible OI treatment and 
        services at all health facilities.

    3. Unequal standards of care: Powerful new antiretroviral drugs are 
transforming the lives of people with HIV in the United States, 
producing much more durable viral suppression, greatly reduced toxicity 
and side effects, and improved prospects for long-term adherence. With 
few exceptions, these new drugs are not available through PEPFAR-
supported ART sites or other treatment support programs. We recognize 
that drug regimen decisions are largely made at the country level, but 
guidance from PEPFAR strongly influences treatment formularies.

   Support provision of quality regimens that are less toxic 
        and more accessible, affordable, and manageable for people 
        living with HIV/AIDS.
   The U.S. should work with countries, generic drug 
        manufacturers, and PEPFAR recipient programs to ensure that 
        there are equitable standards of medical care between the North 
        and South.

    4. Services for young adults: HIV prevalence is mostly impacting 
children and young people between the ages of 9 and 24.

   Funding and programs should specifically target children and 
        young people, and meet the needs of the increasing number of 
        orphans and other vulnerable children. The age bracket 
        receiving support from the OVC earmark should be increased to 
        include young adults, and the percentage of funding for 
        orphans, vulnerable children, and youth should be increased.

    5. Efforts to reach marginalized populations should be expanded: 
Programs should be designed and implemented with respect for the human 
rights of marginalized groups, such as people living with HIV/AIDS, 
orphans and other vulnerable children, women, prisoners, commercial sex 
workers, men who have sex with men, people with disabilities, migrants, 
people living in conflict or post-conflict situations, pastoralists, 
rural populations, ethnic minorities and the elderly. PTMCT services 
are the privilege of a few, and many poor mothers cannot afford 
recommended services, such as alternatives to breast milk. There is a 
new wave of stigma due to existing PEPFAR prevention policies, and 
current programs are insensitive to age, culture, and gender-specific 
needs. The abstinence-only earmark is a distraction from meaningful 
work to reduce rates of new infections in our countries.

   Services should be tailored to meet the needs of vulnerable 
        populations and be accessible, affordable, and within reach.
   Prevention programs should invest in evidence-based 
        preventive strategies that strengthen community-based and peer-
        led awareness creation and behavior change programs, placing 
        vulnerable populations at the center of prevention responses, 
        and addressing the social, economic, and cultural issues that 
        drive new infections.
   Prevention program should be context-specific, include 
        prevention services for people living with HIV/AIDS, and step 
        up efforts to address AIDS-related stigma and gender-based 
   New efforts should be launched to support active outreach to 
        underserved, high-risk groups such as prisoners and people in 
        post-conflict areas.
   PMTCT services should be scaled up to provide nutritional 
        support, alternative infant nutrition, and affordable Cesarean 
        sections for pregnant HIV-positive women.
   PMTCT programs should be linked to AIDS treatment and sexual 
        and reproductive health programs, including family planning, 
        pre-, post-, and antenatal services, and socioeconomic support 
        for mothers.

    6. Lack of medical equipment: Many health facilities--especially in 
rural areas--are poorly equipped in terms of equipment and supplies. In 
particular, countries urgently need CD4 machines and reagents as well 
as x-ray machines. People with HIV are required to show CD4 results or 
x-rays in order to medically qualify for AIDS or tuberculosis treatment 
and to monitor therapies. Too often, the machines are not available in 
any accessible medical facility, or the tests are prohibitively 

   Procure and maintain medical equipment needed to provide 
        AIDS care, including x-ray and CD4 machines and necessary 

    7. Shortages of trained health workers and facilities: There is a 
shortage of health care providers in our countries, and provision of 
primary health care suffers when PEPFAR-supported programs hire away 
scarce health professionals from public sector primary care facilities. 
Training of existing health professionals has not kept pace with the 
scale-up of AIDS programs at the country level, and improved quality 
assurance measures are necessary. Women and people with HIV serving as 
community health workers and home-based care providers bear the brunt 
of providing care and services to people living with HIV/AIDS, but are 
not recognized, supported, or paid. Additionally, access to functioning 
care facilities can be very difficult outside of urban centers, and too 
many rural clinics are understaffed, inadequately equipped, and 
inconsistently supplied.

   U.S. AIDS initiatives should invest to substantially 
        increase the supply of health professionals, support pre- and 
        ongoing in-service training of all cadres of new and existing 
        health workers, and work with countries and professional 
        associations to develop HIV care provider accreditation 
        standards and monitoring.
   Much more should be done to retain existing health workers, 
        including increased remuneration and improved working 
   Community health workers should be trained, certified, 
        equipped, and supported by a functioning referral systems and 
        increased number of health professionals. Community health 
        workers should be paid a wage sufficient to support a family 
        and be integrated into the mainstream health system.
   More health facilities are needed in rural areas, as well as 
        transportation support for patients.

    8. PEPFAR country plans are not aligned with national plans or 
accountable to civil society: U.S. programs are too often operated as 
parallel systems--duplicating, undermining, or even weakening country-
level capacity to respond effectively to health issues. While civil-
society organizations have been at the forefront of the fight against 
AIDS, we are not consulted or meaningfully able to contribute to U.S. 
efforts, policies, plans, and priorities.

   Broader and transparent consultation is needed to ensure 
        that PEPFAR programs are more responsive to country contexts, 
        complement country plans and priorities, and strengthen the 
        country ownership necessary to ensure sustainability.
   PEPFAR should prioritize integrating services into existing 
        programs, especially in public-sector health facilities, rather 
        than running parallel services. Parallel efforts such as the 
        Supply Chain Management System (SCMS) should be required to 
        work with in-country partners to transfer operations over time.
   PEPFAR programs should be developed in consultation with 
        civil-society organizations, including networks of people 
        living with HIV/AIDS and other vulnerable groups, to ensure 
        community ownership, leadership, and sustainability. Future 
        U.S. AIDS initiatives should adopt a bottom-up approach to 
        empower communities to take leadership in policy design and 

    The following organizations developed these recommendations, and 
thank you for considering their inclusion as the U.S. global AIDS 
initiative is reauthorized, reformed, and renewed:

Alex Margery, Tanzanian Network of People Living with HIV/AIDS 
Alice Tusiime, National Coalition of Women with AIDS in Uganda (NACOA)
Ambrose Agweyu, Health Workforce Action Initiative, and Kenya Health 
        Rights Advocacy Forum (HERAF)
Ann Wanjiru, GROOTS Kenya
Beatrice Were, Global AIDS Alliance (Africa)
Carol Bunga Idembe, Uganda Women's Network (UWONET)
Caroline A. Sande, UNAIDS Consultant
Elizabeth Akinyi, International Community of Women Living with HIV/AIDS 
Everlyne Nairesicie, GROOTS Kenya
Flavia Kyomukama, National Forum of PLWHAs Networks in Uganda 
James Kamau, Kenyan AIDS Treatment Access Movement (KETAM)
Joan Chamungu, TNW+ and Tanzanian National Council of People Living 
        with HIV/AIDS (NACOPHA)
Linda Aduda, Kenyan AIDS Treatment Access Movement (KETAM)
Paddy Masembe, Uganda Network of Young People Living with HIV/AIDS 
        (UNYPA Positive)
Maureen Ochillo, ICW
Micheal Onyango, Men Against AIDS in Kenya
Nick Were, East Africa AIDS Treatment Access Movement (EATAM)
Prisca Mashengyero, Positive Women Leaders, Uganda
Rose Kaberia, EATAM

    Plus two additional individuals representing large AIDS treatment 
programs supported largely by PEPFAR, who wish to remain anonymous to 
protect their ability to offer candid assessments.
James Kamau, Kenyan AIDS Treatment Access Movement (KETAM)
Alia Khan, Global AIDS Alliance (DC)
Paul Davis, Health GAP (Global Access Project)

  Responses of Dr. Michel Kazatchkine to Questions Submitted for the 
                        Record by Senator Biden

    Question. The Center for Global Development issued a report 
entitled, ``Following the Funding for HIV/AIDS,'' which analyzed 
PEPFAR, Global Fund, and World Bank funding practices. In its 
recommendations to the Global Fund, the Center advised the Fund to keep 
its focus on funding gaps or underresourced priorities and to reexamine 
strategies to build local capacity. Could you explain your strategy to 
address each of these two important issues over the next 5 years?

    Answer. One of the principal challenges to scaling-up efforts to 
mitigate the impact of HIV/AIDS, tuberculosis and malaria has been a 
country's capacity to effectively deliver services in a given setting. 
These capacity limitations exist within the governmental as well as 
nongovernmental sector and at the national as well as subnational 
level. Despite an increase in overall international resources to 
enhance the response, limitations in financial management, human 
resource management, M&E, training, remuneration for staff, 
communication/information technology and strategic planning may be 
preventing countries from effectively implementing programs and 
reaching their targets.
    In recognition of the comparative advantage of the different 
sectors involved in mitigating the three diseases, and areas where 
added capacity may not be harnessed, the Global Fund Board passed a key 
Decision Point in April 2007 entitled ``Strengthening the Role of Civil 
Society and the Private Sector in the work of the Global Fund.'' The 
Decision Point calls upon the Global Fund to strengthen key areas of 
its architecture in order to improve upon the effectiveness of the role 
of nongovernmental stakeholders in Global Fund processes, such as 
increasing the participation of key affected populations on Country 
Coordinating Mechanisms (CCMs), providing further guidance on the 
representation of civil society and private sector representatives to 
be members of CCMs, simplified access to CCM funding, and of particular 
relevance, the utilization of dual-track financing (DTF) \1\ and the 
funding of community systems strengthening (CSS) to address gaps and 
constraints to national scale-up.
    \1\ DTF refers to the recommendation that CCMs routinely select 
both government and nongovernment sector Principal Recipients to lead 
program implementation in proposals submitted the the Global Fund.
    Both dual-track financing and community systems strengthening are 
designed to increase the role and effectiveness of both the 
governmental and nongovernmental sectors in implementation and service 
delivery, as well as to develop a longer term strategy for 
institutional development of the weaker sectors, to take on a greater 
role in service provision in the future.
    Dual Track Financing: Starting in Round 8, countries submitting 
applications to the Global Fund will be encouraged to nominate both a 
governmental and nongovernmental PR and will be required to provide a 
detailed explanation in the case that the proposal does not nominate, 
at a minimum, one Principal Recipient (PR) from each sector. The 
governmental sector has often demonstrated its comparative advantage in 
the provision of health infrastructure, the procurement of essential 
medicines, the training of national, district and local-level health 
professionals, as well as implementing larger scale programs at the 
national level.
    Civil society organizations, similarly, are becoming increasingly 
recognized for their role in scaling up access to treatment, through 
the targeting of communities to increase uptake in more formal health 
settings and treatment literacy; as well as their acknowledged role in 
reaching vulnerable and marginalized populations which the governmental 
sector may have more difficulty accessing. Through working together at 
a national level, these sectors would be able to provide a more 
holistic and comprehensive response to the three diseases as well as to 
develop sustainable partnerships for service delivery for the long 
    Community Systems Strengthening: Proposals submitted may already 
include activities that strengthen the community-level response to the 
three diseases. However it is recognized that weaknesses at the 
community level affect the performance of existing grants, as well as 
overall demand for and access to services. The proposal form and 
guidelines for Round 8 therefore provide greater encouragement to 
applicants to include provision for strengthening and/or further 
development of community systems and institutional capacity to ensure 
improved outcomes for the three diseases. This encouragement takes the 
form of increased information on potential indicators, and also 
commentary on anticipated improvement in community systems. In this 
context, the Global Fund describes CSS as funding to build the capacity 
of community-based organizations, including NGOs, to improve and expand 
service delivery (for example, home-based care, outreach, prevention, 
orphan care, etc.).
    Funding for CSS may go to:

   Subrecipients (SRs), and as relevant, sub-subrecipients 
        (SSRs) of existing Global Fund grants in anticipation of 
        building sufficient capacity for a PR nomination in a future 
   Other already existing local and subnational CBOs who do not 
        already have established relationships within the Global Fund 
        framework, but have the potential to be key partners in the 
        delivery of services; and
   Young or emerging CBOs (initiated within approximately the 
        last 5 years) and/or organizations little or no track record in 
        attracting or managing outside finances.

    CCMs will be required to demonstrate and identify in future 
proposals all gaps to enhanced service delivery, and in this particular 
case, gaps which prevent it from utilizing the capacity of both sectors 
at the PR-level to implement dual track financing and gaps and 
constraints in the ability of governmental and nongovernmental 
organizations at the subnational level to scaling up effective 
responses to the three diseases. From Round 8, applications which seek 
to implement the DTF model or demonstrate the need for CSS funding at 
the subnational level, in particular among CBOs, would therefore be 
eligible for funding throughout the life of the grant.

    Question. U.S. law requires a ``snapshot'' of international 
contributions that have been made to the Global Fund as of July 31 of 
each year. How does the timing of this snapshot affect the funding 
process? As Congress considers reauthorization of global HIV/AIDS, 
tuberculosis, and malaria programs, are there alternatives to current 
practice that would provide a window into--and perhaps help spur--
international contributions but that might remedy reported difficulties 
stemming from the July 31 deadline?

    Answer. The July 31 deadline poses problems because almost all 
other major donors have different financial years. For example, most 
European donors follow their own calendars and pay their contributions 
at the end of the year. Therefore, the July deadline is problematic to 
these donors, essentially forcing them to transfer their money earlier. 
To date, other donors have obliged, but to improve our relationships 
with donors, it would be helpful to have this deadline shifted or 

    Question. The Global Fund does not have a particular grant category 
to address the needs of women and girls, but all involved recognize 
that women are physically, economically, and socially more vulnerable 
to HIV/AIDS. Could you tell us how the Global Fund is helping to 
address these gender issues within its grants?

    Answer. The Global Fund fully recognizes the particular 
vulnerability of women and girls to HIV/AIDS and is already funding a 
number of programmes supporting activities that benefit this population 
    There is evidence that many of the Global Fund programmes are 
reaching women. Of the 1.1 million people on antiretroviral therapy by 
mid-2007, 57 percent were women who represent 48 percent of infections. 
Other activities currently underway range from care and treatment 
programs for sexually exploited underage girls in Costa Rica, to 
supporting grandmothers who care for orphans in Swaziland and financing 
a network of HIV-positive women in Kenya working on antidiscrimination 
and the social integration of women living with HIV and AIDS.
    Despite the many interventions that can be catalogued, the Global 
Fund is acutely aware of the disproportionate burden placed on women by 
AIDS and of their unique vulnerability. Therefore, the Global Fund is 
emphasizing the need to develop and expand programs targeted at women 
and girls in future proposal rounds. In addition, in November 2007 the 
Global Fund Board made a key decision regarding the importance of 
gender and the particular importance of women and girls:
 scaling up a gender-sensitive response to hiv/aids, tuberculosis, and 
                       malaria by the global fund
Decision Point GF/B16/DP26:
    The Board recognizes the importance of addressing gender issues, 
with a particular focus on the vulnerabilities of women and girls and 
sexual minorities, in the fight against the three diseases, more 
substantially into the Global Fund's policies and operations.
    The Board authorizes the Secretariat as a matter of priority to 
immediately appoint senior level ``Champions for Gender Equality,'' 
with appropriate support, who will:

          a. Work with technical partners and relevant constituencies 
        to develop a gender strategy.
          b. As an immediate priority, provide guidance to the 
        Portfolio Committee on revisions to the Guidelines for 
        Proposals for Round 8 to encourage applicants to submit 
        proposals that address gender issues, with a particular 
        reference to the vulnerability of women and girls and sexual 

    The Board requests the Policy and Strategy Committee to review the 
Gender Strategy and present it to the Board for approval at the 17th 
Board meeting.
    The Global Fund Secretariat has recruited a consultant to ensure 
that work on this initiative starts immediately. In addition, an 
intense consultation process was undertaken to ensure the Round 8 
Guidelines for Proposal are appropriately adjusted to reflect this 
priority and encourage countries to ensure their programming takes into 
account gender as a factor of the epidemics and that they plan 
    The recruitment of the gender champions will begin as soon as the 
role has been properly defined in the context of a strategic framework. 
The Global Fund is working with partners to ensure that appropriate 
technical assistance is available to ensure evidence-based and 
technically sound proposals on this area are prepared for submission 
for Round 8.

 Responses of Dr. Helen Smits to Questions Submitted for the Record by 
                             Senator Biden

    Question. PEPFAR has made real strides in addressing issues of 
gender and the special needs of women and girls, but we have not been 
able to keep pace with the spread of the pandemic or the fact that 
women are increasingly among its victims. Women and girls are 
physically more vulnerable to HIV/AIDS, but economic, political, and 
legal disparities make them more so. In many countries, such as South 
Africa, young women are four times more likely to be HIV-infected than 
young men.

   Specifically, how can efforts to address the special 
        vulnerabilities and needs of women and girls be expanded and 
        improved in the next phase of our HIV/AIDS efforts?

    Answer. The IOM report recommends that the U.S. Global AIDS 
Initiative continue to increase its focus on the factors that put women 
at greater risk of HIV/AIDS and to support improvements in the legal, 
economic, educational, and social status of women and girls. The IOM 
committee believes such improvements are necessary to create conditions 
that will facilitate the access of women and girls to HIV/AIDS 
services; support them in changing behaviors that put them at risk for 
HIV transmission; allow them to better care for themselves, their 
families, and their communities; and enhance their ability to lead and 
be part of their country's response to its HIV/AIDS epidemic.
    Specifically, the IOM committee was encouraged by OGAC's formation 
of the Technical Working Group on Gender and the focus that it could 
bring on the needs of women and girls and approaches to meet them. The 
IOM committee also urges the Global AIDS Coordinator to keep his 
commitment to implement expeditiously the recommendations developed as 
a result of the June 2006 ``Gender Consultation'' hosted by PEPFAR.
    Although the IOM study was not designed to judge the effectiveness 
of individual programs, I would like to add my personal impression, 
from the country visits, of the very exciting and relatively low-cost 
programs underway. Many of the ones I saw are based in local NGOs with 
a strong sense of what local women can do to achieve economic 
independence. In the legal sense, these include programs to counsel 
women when traditional practices (such as the personal dwelling 
reverting to the husband's family at his death) are in conflict with 
national law. I met a number of women who had been able to retain their 
control over their home and its contents--a huge step in surviving 
widowhood. I also saw programs which provided women with both training 
and modest capital in order to become independent entrepreneurs; these 
programs included raising chickens and selling them in the market, 
selling soft drinks, and creating crafts with a ``western'' look that 
has enabled the groups of women to sell to major international 
    I am sure with the experience already gained, the Technical Working 
Group on Gender will be able to advise all PEPFAR countries in the 
development of strong programs in this important area.

    Question. Are current targets and indicators on gender sufficient?

    Answer. The IOM committee did not find any ``targets'' per se for 
women and girls, and is in principle supportive of meaningful targets 
for desired program outcomes. PEPFAR reports on the number of programs 
and services it supports that are directed at reducing the risks faced 
by women and girls in the following categories: (1) Increasing gender 
equity, (2) addressing male norms, (3) reducing violence and sexual 
coercion, (4) increasing income generation for both women and girls, 
and (5) ensuring legal protection and property rights. However, no 
information of the kind the IOM committee would like to see was yet 
available--that is, information with which to determine either the 
individual or collective impact of these activities on the status of, 
and risks to, women and girls.
    Consistent with its call for better data about focus country 
epidemics, support for country monitoring and evaluation systems, and 
evaluation of the impact of PEPFAR-supported programs, the IOM 
committee would want the U.S. Global AIDS Initiative to develop and be 
accountable for harmonized indicators of the health and other status of 
women and girls. The kinds of indicators that are under discussion 
include the length of schooling for girls, evidence of implementation 
of property right laws, and numbers of women engaged in productive work 
that generates an income sufficient for family survival.

Responses of Dr. Nils Daulaire to Questions Submitted for the Record by 
                             Senator Biden

    Question. PEPFAR has made real strides in addressing issues of 
gender and the special needs of women and girls, but we have not been 
able to keep pace with the spread of the pandemic or the fact that 
women are increasingly among its victims. Women and girls are 
physically more vulnerable to HIV/AIDS, but economic, political, and 
legal disparities make them more so. In many countries, such as South 
Africa, young women are four times more likely to be HIV-infected than 
young men.

   Specifically, how can efforts to address the special 
        vulnerabilities and needs of women and girls be expanded and 
        improved in the next phase of our HIV/AIDS efforts?
   Are current targets and indicators on gender sufficient?

    Answer. One of the first ways to address the special 
vulnerabilities and needs of women and girls is linking PEPFAR with an 
overall health and development strategy. To date, PEPFAR has been 
implemented in a vertical, medical model which does not allow for 
addressing nonmedical concerns such as access to basic services. This 
lack of access exacerbates the vulnerability of women and girls. U.S. 
investments in HIV/AIDS must be coupled with adequate and increased 
assistance to core health and development programs.
    Better wraparound programs are needed to adequately address the 
needs of women and girls including better referral services to non-HIV 
health services such as maternal health, reproductive health, etc. 
Prevention and treatment programs need to be integrated into maternal 
and child health clinics in order to better reach women. Women also 
need increased access to basic health services.
    The means of evaluating PEPFAR programs success need to be revised 
across the board. Currently, OGAC is primarily focused on output 
indicators. Output indicators do not really help in determining how to 
improve a program. They help generate quantifiable results. Our 
implementing agencies are calling for more outcome indicators including 
those used for gender assessments.
    PEPFAR also needs to strengthen programs that address gender-based 
violence by working with countries to establish better social, medical, 
and legal referral systems for victims of sexual violence, integrating 
gender-based violence screening into HIV programs and providing post-
exposure prophylaxis and emergency contraception.
    Overall, GHC implementing agencies feel that OGAC is on the right 
track for addressing gender needs. It is a question of how to scale up 
projects and integrate PEPFAR services with other health services. 
Implementing agencies are also calling for increased focus on stigma as 
this affects women and girls more. We need to know more about OGAC's 
work around stigma and discrimination to better help address the 
vulnerabilities of women and girls.
    Modification of policy restrictions such as the antiprostitution 
pledge and abstinence until marriage earmarks would also help increase 
outreach to women.

    Question. How do shortages of health care workers and shortcomings 
in health systems affect your organization's (or your member 
organizations') efforts to combat HIV/AIDS, TB, malaria, and other 
health challenges? What are the most important steps to take in the 
next phase of our HIV/AIDS, TB, and malaria programs to try to address 
these challenges?

    Answer. Global Health Council member organizations implementing 
HIV/AIDS programs have cited lack of human resource capacity as a 
critical issue. According to our agencies, achieving PEPFAR targets in 
a sustained way is going to be practically impossible without an 
appropriate strategy for addressing the human resource issue. 
Currently, according to our member partners, not enough PEPFAR 
resources are available for training new health care workers or for 
building health infrastructure. As such, organizations often have to 
rely on using their own health personnel or have to pull health 
personnel away from non-HIV primary health care services. This results 
in scaling back in other non-HIV programs and services.
    Furthermore, there currently is no support to assist countries in 
conducting national human resource forecasting to help determine 
capacity required to implement a project. Organizations have called for 
scaling up of community-based workers but these workers must be 
integrated into a primary health care system. While the task shifting 
approach can have positive impacts by allowing nurses to manage ART 
patients, this approach must be carefully implemented so as not to 
further siphon away health personnel from non-HIV health services.
    Another challenge is the type of training. Most PEPFAR health care 
worker training is limited to administering ARV drugs. However, there 
remains a significant lack of trained health care workers in pediatrics 
and palliative care. According to our members, many patients on ART are 
dying of opportunistic infections in part due to lack of trained health 
care workers to diagnose and treat opportunistic infections.
    Our member organizations are also concerned about not having enough 
trained professionals in the area of pediatric HIV/AIDS. A number of 
children and infants are not being reached through treatment, care or 
prevention programs and even if they are, services are limited due to a 
shortage of trained health professionals.
    Training also needs to be increased in the areas of counseling and 
testing, prevention education and other activities, and in other types 
of counseling such as nutritional counseling. Ideally trained health 
professionals working in HIV/AIDS also need to be able to detect other 
global health needs such as childhood malnutrition, preventable 
diseases such as pneumonia.
    Lack of health infrastructure is even a bigger challenge than 
trained health care workers. PEPFAR must start building primary health 
care infrastructure instead of HIV-only infrastructures. Only recently 
has OGAC begun to use the primary health care model for delivering HIV 
programs and services.

   Many have called for greater linkage between food and 
        nutrition assistance and efforts to combat HIV/AIDS.

     How does food insecurity affect efforts to combat HIV/AIDS?
     What are the barriers to greater integration?
     What are the dangers of providing food assistance only to 
            those who are AIDS-affected when food insecurity in an area 
            is widespread and help for those who are not HIV positive 
            may not be available? Should we have an individual-centered 
            approach, a family-centered approach, or a community-
            centered approach?

    According to many experts, World Health Organization, UNAIDS, and 
our own implementing agencies, high malnutrition rates are present in a 
number of HIV-affected communities, particularly in sub-Saharan Africa. 
Food is often identified as most immediately needed by people living 
with HIV/AIDS. Our implementing organizations are concerned about 
scaling up care and antiretroviral therapy without planning for 
appropriate nutrition. They have found that adherence to ARV is low 
when an individual with HIV/AIDS lacks proper nutrition.
    However, Global Health Council implementing agencies have found it 
difficult to integration nutrition and HIV. Barriers to integrating 
food and nutrition assistance with HIV/AIDS programs and services are 
the same for any ``wrap around'' activity. There are two challenges: 1. 
Coordination; 2. Funding.
    The first problem is that there appears to be a lack of 
coordination amongst agencies. Currently, to our knowledge, there is 
not a joint assessment among agencies on the needs of an HIV-affected 
community (not just for HIV programs and services but what else is 
needed: Food, water, doctors, etc). Individual implementing 
organizations have to tie the various pieces together themselves. For 
example, if an organization is working in an HIV-affected community 
that also lacks access to food or water, the organization itself must 
coordinate with other agencies like World Food Programme or USAID's 
Public Law 480 rather than OGAC coordinating ahead of time with the 
World Food Programme. Organizations must then rely on availability of 
funding through other sources and must also address different 
procurement mechanisms and a different funding cycle which adds to the 
reporting burdens.
    Furthermore, PEPFAR programs and food programs are often in 
different locations which makes coordinating even more difficult.
    Finally, funding is an issue. Core programs, including food aid, 
have not grown at the same rate as PEPFAR. Additional funding to 
support non-HIV services in PEPFAR programs has not been available. If 
it is available, it is coming at the expense of services accessed by 
nonheavily affected HIV communities.
    As far as providing assistance is concerned, a number of our 
implementing agencies have long called for a community-centered 
approach. Several implementing agencies, particularly partners working 
with orphans and vulnerable children have experienced problems as they 
are seen as favoring HIV-positive families in communities where those 
who are HIV negative are still coping with significant health issues.
    global health council recommendations for pepfar reauthorization
    We would also request that attached recommendations be inserted 
into the record.
    In addition to the attached recommendations, we also call on 
Congress to remove the antiprostitution pledge (APP). There is no 
evidence that the APP has improved HIV prevention. It has alienated 
some U.S. Government partners and created uncertainty for others. It is 
a disincentive for innovative programming with sex workers as program 
implementers fear inadvertently breaching the pledge requirement. The 
``pledge'' further stigmatizes the vulnerable people we are trying to 
reach and serve, making prevention efforts more difficult. It has also 
raised constitutional issues and has been struck down by two Federal 
district courts, though the appeals process is still under way. We see 
no point in the Congress prolonging a legal battle with the 
government's partners in the fight against AIDS over a provision that 
does not improve public health outcomes.
    Finally, the Global Health Council, recommends that the U.S. 
Congress and the U.S. President work together to develop a more 
comprehensive response to global health needs, which would include 
developing a longer term global health strategy that guides all U.S 
global health programs, including PEPFAR. A comprehensive approach to 
global health would be informed by analyses of the causes of the 
greatest burden of disease in the world's poorest countries and a 
commitment to supporting long-term development needs in partner 
countries as well as taking advantage of public diplomacy opportunities 
to strengthen America's reputation abroad. With the support of the U.S. 
Congress, this administration has achieved extraordinary results in 
global health through PEPFAR and increasingly through the President's 
Malaria Initiative. However, as an alliance of public health experts, 
we know that health is not achieved by fighting specific diseases in 
isolation. In order to combat HIV/AIDS successfully, U.S. programs on 
global HIV/AIDS must evolve from an emergency response to a long-term 
investment in global health that is connected to achieving our other 
goals in areas, such as reducing maternal and child mortality, 
combating other infectious diseases and access to basic development 
services such as water and sanitation.

[Attachment follows:]
    summary of the global health council member recommendations for 
                          strengthening pepfar
    The President's Emergency Plan for AIDS Relief (PEPFAR), is a 5-
year, $15 billion, comprehensive approach for combating HIV/AIDS in 15 
focus countries. The program, and the legislation that supported it, 
will expire in 2008. To assure the continuation of PEPFAR and 
strengthen the U.S. Government response to the pandemic, the Global 
Health Council convenes a group of its members with expertise in 
implementing HIV programs. Under the Council's leadership, 
representatives of its member organizations developed the following 

recommendations for improving the implementation of pepfar programs and 

1. HIV/AIDS Prevention Efforts Must Be Scaled Up
    Council members endorse the administration's proposal to increase 
the number of people reached by HIV/AIDS prevention programs from 7 
million to 12 million. Members support developing prevention strategies 
tailored to the needs of specific types of epidemics and populations 
that are designed at the country level and based on evidence of what 
interventions are effective. In order to provide prevention programs to 
significantly more people, members recommend eliminating the 
prostitution pledge and modifying guidance on harm reduction, which 
currently only allows for prevention interventions among HIV-positive 
injecting drug users.
2. More Flexibility Is Needed in PEPFAR's Budgetary Allocations
    Members support modifying budgetary allocations to allow for 
country-specific and epidemic-specific programming.
3. Increase Ability To Use PEPFAR Resources Between Program Areas and 
        Between HIV and non-HIV Health Services
    Create the policy and budgetary environment to support more 
wraparound services or linkages between HIV and non-HIV services. This 
includes allowing the flexibility in use of funds for integrated 
programming such as child immunizations in a PEPFAR pediatric treatment 
4. Expand Treatment and Care Programs and Improve Quality of Treatment 
    Members support expanding access to antiretroviral therapy through 
public-private partnerships; expanding technical support and resources 
to increase access to palliative care; increasing acccess for infants 
and children for diagnosis and care and treatment services; improving 
patient followup practices; and recognizing the World Health 
Organization (WHO) prequalification process for availability of drugs.
5. Train Additional Health Care Workers and Strengthen Health Systems
    Members support using PEPFAR resources to increase the number of 
health care workers in HIV-affected communities to contribute to, not 
draw down from, the total number of health care workers. Members 
recommend training more workers particularly in providing palliative 
care, pediatric treatment and diagnosis, and in the ability to provide 
other sets of services for HIV patients. Members support using PEPFAR 
resources to strengthen the health system in HIV-affected communities
6. Improve and Expand Operations Research
    PEPFAR is a learning organization and as such it should modify and 
improve its current monitoring and evaluation process and devote more 
resources to operations research. Members recommend that PEPFAR 
communicate more with implementing agencies to share best practices and 
lessons learned to help inform policy and budgetary decisions in the 

   Responses of Ken Hackett to Questions Submitted for the Record by 
                             Senator Biden

    Question. PEPFAR has made real strides in addressing issues of 
gender and the special needs of women and girls, but we have not been 
able to keep pace with the spread of the pandemic or the fact that 
women are increasingly among its victims. Women and girls are 
physically more vulnerable to HIV/AIDS, but economic, political, and 
legal disparities make them more so. In many countries, such as South 
Africa, young women are four times more likely to be HIV-infected than 
young men.

   Specifically, how can efforts to address the special 
        vulnerabilities and needs of women and girls be expanded and 
        improved in the next phase of our HIV/AIDS efforts?

    Answer. It is true that PEPFAR has made real strides in addressing 
issues of gender and the special needs of women and girls during the 
first 4 years of its implementation. However, it has not done enough to 
prevent HIV transmission among women, which is now the largest growing 
population of PLHIV. Catholic Relief Services, a major implementing 
partner of PEPFAR, is managing the AIDSRelief project under which 
nearly a quarter of a million PLHIV are in care; consistent with other 
PEPFAR ART providers, close to 70 percent of PEPFAR-supported ART 
patients are women. Moreover, of the 153 CRS AIDSRelief local partner 
treatment facilities which provide care on a daily basis to the 
patients, more than 30 offer Prevention to Mother to Child Transmission 
    To improve our capacity to address gender issues in our HIV 
response, CRS will carry out a study in 2008 to determine how best to 
improve gender mainstreaming across the agency, including an assessment 
of current strengths and gaps in gender programming and an industrywide 
review of State of the Art gender programming.
    CRS believes that PEPFAR can address the special vulnerabilities 
and needs of women and girls by recognizing that simply by being female 
is to be at high risk of HIV and AIDS. PEPFAR can implement a global 
HIV prevention strategy that emphasizes the root causes of these 
vulnerabilities and the factors that affect their rate of HIV 
infection. Some of the activities which should be included in this HIV 
prevention strategy are:

                    girls education and life skills

   Supporting expanded and safe educational opportunities for 
        women and others at risk, including curricular and 
        infrastructural reforms to address social nouns and reduce risk 
        of school dropout of girl children.
   Supporting age-appropriate life skills education for young 
        girls so that they are informed how best to protect themselves, 
        from HIV infection, through delay of sexual debut (abstinence 
        until marriage) and partner reduction (faithfulness in 
    women's economic empowerment and strengthening their livelihoods
   Supporting the development of livelihood initiatives, access 
        to markets, job training and literacy and numeracy programs, 
        and other such efforts to assist women and girls in developing 
        and retaining independent economic means.
   Supporting the development and expansion of local and 
        community groups focused on the needs and rights of women and 
        girls; and involving these organizations at the community level 
        in program planning and implementation.

                   reducing stigma and discrimination

   Preventing violence against women, including intimate 
        partner and family violence, sexual assault, rape and domestic 
        and community violence against women and girls.
   Encouraging the participation and involvement of local and 
        community groups representing different aspects of women's 
        lives in drafting, coordinating, and implementing the national 
        HIV/AIDS strategic plans of their countries.
   Promoting changes in social norms attitudes and behavior 
        that currently condone violence against women, especially among 
        men and boys, and that promote respect for the rights and 
        health of women and girls, reduce violence, and support and 
        foster gender equality.

              legal support for women affected by hiv/aids

   Protecting the property and inheritance rights of women 
        through direct services as well as legal reforms and 

    Question. Are current targets and indicators on gender sufficient?

    Answer. No; current targets and indicators are not sufficient.
    PEPFAR should invest in the disaggregation of data by age as well 
as sex to better understand HIV infection trends among different age 
groups; expand operations research and evaluations of gender-responsive 
interventions in order to identify and replicate effective models; 
develop gender indicators to measure both outcomes and impacts of 
interventions, especially interventions designed to reduce gender 
inequalities; develop and encourage the utilization of gender analysis 
tools at the country level, and disseminate lessons learned among 
different countries.
    PEPFAR must not only disaggregate its data, but also must develop 
indicators to measure the effectiveness of gender programming, and the 
extent to which gender is being mainstreamed into PEPFAR. PEPFAR must 
be able to report which programs are working to address the needs of 
women PLHIV, such as expanding PMTCT, but also which programs are 
working to reverse discrimination and stigma, such as sensitivity 
training for men. Moreover PEPFAR must report which programs are 
working to increase women's education and economic empowerment, as well 
as increase young women's life skills. PEPFAR should not only state how 
many projects or programs support these strategies, but also measure 
the impact of these programs through evidence-based reporting.

    Question. How do shortages of health care workers and shortcomings 
in health systems affect your organization's (or your member 
organizations') efforts to combat HIV/AIDS, TB, malaria, and other 
health challenges? What are the most important steps to take in the 
next phase of our HIV/AIDS, TB, and malaria programs to try to address 
these challenges?

    Answer. Catholic Relief Services leads a consortium which 
implements a PEPFAR-funded antiretroviral therapy project AIDSRelief--
that provides life-saving antiretroviral medications for 90,000 
patients and provides care for another 146,000 HIV-positive people 
through 153 local partners in nine countries. Some AIDSRelief partners 
are approaching a ``ceiling'' in the number of people that they can 
treat and care for, not because of lack of drugs, but because of lack 
of trained health care personnel.
    Most countries lack sufficient trained medical professionals and 
other trained health personnel to support and supervise care and 
treatment as they scale-up beyond the large numbers of people in need 
of ART. It is estimated that the African Continent has a shortage of 2 
million trained health professionals. Brain-drain, emigration, and 
poaching of trained health professionals to meet the health 
professional shortages in the developed world (principally North 
America and Europe), as well as attrition by death due to AIDS, are all 
contributing factors to this shortage.
    As a result, CRS-led AIDSRelief has been working with alternative 
nurse-led models of care and task shifting from physicians to nurses, 
and nurses to community health workers (CHWs) and volunteers. Our 
partners train and supervise many CHWs and volunteer treatment 
``buddies'' (or treatment coaches)--many of whom are PLHIV on ART 
    Because of task shifting and the resultant mobilization of large 
numbers of CHWs and volunteers among CRS-led AIDSRelief partners, we 
are experiencing 85-95 percent retention rates of our patients in the 
program. Those who remain in the program are 80-95 percent adherent to 
their antiretroviral medication regimen. This results in successful 
viral suppression and the ability to keep most patients on less-
expensive first-line drugs.
    What can be done to ensure sufficient health care workforce and 
thus the ability to maintain current patients on successful therapy and 
also to scale-up? More funding in PEPFAR for training, supervision, 
continuing education, upward mobility in the health care workforce, and 
some kind of compensation package (salaries for full-time CHWs and 
stipends/incentives for volunteer treatment buddies/coaches) would help 
ensure the ability of CRS-led AIDSRelief partners to continue and 
expand services.
    In addition, in several developing countries, there is an 
intermediary level of trained professional between that of physicians 
and nurses called a ``clinical officer,'' a level that does not exist 
in North America and Europe. As a result, clinical officers are not 
``exportable'' to other health systems outside of their home country 
and are therefore more likely to provide long-term HIV diagnosis, care, 
and treatment services in their home country. Training more ``clinical 
officers'' would thus provide one avenue for a more stable workforce.

    Question. Many have called for greater linkage between food and 
nutrition assistance and efforts to combat HIV/AIDS.

   How does food insecurity affect efforts to combat HIV/AIDS?

    Answer. The No. 1 issue that we hear from people living with HIV 
and AIDS and their families in the 52 countries where we have HIV 
programming, is lack of food and the money to purchase it. All aspects 
of food insecurity availability, access and use of food--are 
exacerbated by high rates of HIV and AIDS. The chronic and debilitating 
progression from HIV infection to full-blown AIDS (if untreated or 
treated late) accompanied by the loss of work and income while seeking 
treatment leads to hunger, poor nutrition, and food insecurity.
    HIV significantly undermines a household's ability to provide for 
basic needs because HIV-infected adults may be unable to work, reducing 
food production and/or earnings. Healthy family members, particularly 
women, are often forced to stop working to care for sick relatives, 
further reducing income for food and other basic needs. Households may 
have trouble paying costs associated with heath care and nutritional 
support. They may also be severely restricted in participating in 
community activities. Children may be withdrawn from school because 
families can no longer afford school fees and/or because children are 
needed to care for ill parents. This affects opportunities for future 
generations. Furthermore, as a result of this HIV-to-poverty or 
poverty-to-HIV cycle, the quantity and quality of diet diminishes for 
the entire PLHIV household.
    The interaction between nutrition and ART is well documented. 
Inadequate nutrition causes malabsorption of some ARVs. Some 
medications have to be taken on an empty stomach, while others with a 
fatty meal. Preliminary evidence from the 153 CRS AIDSRelief ART sites 
suggests that patients initiating ART with access to food respond to 
treatment better than those lacking adequate nutrition. Continued data 
collection is important for a more comprehensive picture.

    Question. What are the barriers to greater integration?

    Answer. Short-term food/nutrition supplements and household basket 
rations, while necessary, do not address underlying food insecurity.
    Food and nutrition and HIV activities are not well-integrated 
across various USG agencies and programs. Title II food programs are 
targeted to geographical regions with the greatest food insecurity, 
which does not always allow us to reach food insecure PEPFAR-supported 
OVC and PLHIV living in other regions of the same country. In addition, 
interagency coordination and integration of services is not always 
consistent across countries.
    CRS' AIDSRelief ART Project uses PEPFAR funding to provide ``Food 
by Prescription'' to ART patients meeting certain stringent physical 
biometric criteria in Kenya and Uganda where other food/nutrition 
resources are not available. This creative and needed approach is not 
currently available in other PEPFAR focus countries.
    Cutbacks in Title II funding have exacerbated the challenge. 
Successful projects like I-LIFE, RAPIDS, SUCCESS, and Return to Life in 
the southern Africa region have led to better integration of HIV and 
nutrition programs with sustainability by targeting the causes of food 
insecurity. All have not received continued or expanded funding because 
of Title II cutbacks. A recent SUCCESS (Scaling Up Community Care to 
Enhance Social Safety-nets) evaluation report shows the overwhelmingly 
positive impact of nutritional supplements on HIV-positive home-based 
care clients not taking ARVs that also met household food insecurity 
criteria for targeted nutritional supplementation.
    In addition, shortages of health care workers, including 
nutritionists, limit the time and ability of existing staff to provide 
food/nutrition counseling.

    Question. What are the dangers of providing food assistance only to 
those who are AIDS-affected when food insecurity in an area is 
widespread and help for those who are not HIV positive may not be 

    Answer. From our almost 50 years of food aid experience with Title 
II, when food is given only to the patient, we have observed that 
individual food rations are usually shared with the rest of the 
household--diminishing the intended benefit to the individual. As a 
result, CRS strives to use other resources--from Title II, WFP, and our 
private funds--to distribute basket rations to families and households 
affected by HIV. The key to avoiding unintended jealousy or conflict in 
the community is to involve the community in targeting these basket 
rations to those most in need.
    While the following is not from a PEPFAR-supported program, it 
illustrates the value of basket rationing to households--the preferred 
model of nutritional support for HIV-affected families. Through the 
Public Law 480 Title II-supported I-LIFE program in Malawi, CRS and its 
partners provide food assistance to the chronically ill (most of whom 
are PLHIV) and their households. This helps entire households maintain 
a healthy nutritional status, provides for increased calorie and 
protein needs of those infected, eases the time and resource 
constraints of caregivers, and allows other members living in 
vulnerable households to pursue productive livelihoods. I-LIFE also 
provides community education programs that incorporate information 
about HIV prevention, health and nutrition, and challenge the stigma 
associated with the disease. Through these interventions CRS and its 
partners reduced food insecurity and eased the effects of the HIV and 
AIDS epidemic in the region. Unfortunately, many beneficial Title II-
supported programs like I-LIFE have either ended or are in their last 
year because of Title II funding cuts.

    Question. Should we have an individual-centered approach, a family-
centered approach, or a community-centered approach?

    Answer. The approach has to be flexible to respond to the varying 
needs in any given HIV-affected population. However, family and 
household basket food rations will be most appropriate in cases where 
affected individuals live in families that have used all available 
resources and coping mechanisms to meet the needs of the HIV-infected 
individual and have nothing left to meet the nutritional needs of 
either the patient or the household. Providing food to the HIV-infected 
individual in a food insecure household will lead the infected 
recipient of an individual ration to share the ration with all members 
in the household; this then fails to meet the urgent nutritional need 
of the targeted HIV-infected recipient and is also insufficient to meet 
the food security needs of the other members of the household. Done 
correctly, community involvement is key to successful identification of 
individuals and households in need of nutrition and food assistance 
without causing jealousy among the rest of the community.