    [House Hearing, 111 Congress]
    [From the U.S. Government Publishing Office]

        U.S. INVESTMENTS IN HIV/AIDS: OPPORTUNITIES AND CHALLENGES AHEAD

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

                                    HEARING

                                   BEFORE THE

                    SUBCOMMITTEE ON AFRICA AND GLOBAL HEALTH

                                     OF THE

                          COMMITTEE ON FOREIGN AFFAIRS
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED ELEVENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 MARCH 11, 2010

                                   __________

                               Serial No. 111-104

                                   __________

            Printed for the use of the Committee on Foreign Affairs

     Available via the World Wide Web: http://www.foreignaffairs.house.gov/

                                     ______

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                          COMMITTEE ON FOREIGN AFFAIRS

                     HOWARD L. BERMAN, California, Chairman
    GARY L. ACKERMAN, New York           ILEANA ROS-LEHTINEN, Florida
    ENI F.H. FALEOMAVAEGA, American      CHRISTOPHER H. SMITH, New Jersey
        Samoa                            DAN BURTON, Indiana
    DONALD M. PAYNE, New Jersey          ELTON GALLEGLY, California
    BRAD SHERMAN, California             DANA ROHRABACHER, California
    ELIOT L. ENGEL, New York             DONALD A. MANZULLO, Illinois
    BILL DELAHUNT, Massachusetts         EDWARD R. ROYCE, California
    GREGORY W. MEEKS, New York           RON PAUL, Texas
    DIANE E. WATSON, California          JEFF FLAKE, Arizona
    RUSS CARNAHAN, Missouri              MIKE PENCE, Indiana
    ALBIO SIRES, New Jersey              JOE WILSON, South Carolina
    GERALD E. CONNOLLY, Virginia         JOHN BOOZMAN, Arkansas
    MICHAEL E. McMAHON, New York         J. GRESHAM BARRETT, South Carolina
    JOHN S. TANNER, Tennessee            CONNIE MACK, Florida
    GENE GREEN, Texas                    JEFF FORTENBERRY, Nebraska
    LYNN WOOLSEY, California             MICHAEL T. McCAUL, Texas
    SHEILA JACKSON LEE, Texas            TED POE, Texas
    BARBARA LEE, California              BOB INGLIS, South Carolina
    SHELLEY BERKLEY, Nevada              GUS BILIRAKIS, Florida
    JOSEPH CROWLEY, New York
    MIKE ROSS, Arkansas
    BRAD MILLER, North Carolina
    DAVID SCOTT, Georgia
    JIM COSTA, California
    KEITH ELLISON, Minnesota
    GABRIELLE GIFFORDS, Arizona
    RON KLEIN, Florida
    VACANT
                       Richard J. Kessler, Staff Director
                    Yleem Poblete, Republican Staff Director
                                     ------

                    Subcommittee on Africa and Global Health

                     DONALD M. PAYNE, New Jersey, Chairman
    DIANE E. WATSON, California          CHRISTOPHER H. SMITH, New Jersey
    BARBARA LEE, California              JEFF FLAKE, Arizona
    BRAD MILLER, North Carolina          JOHN BOOZMAN, Arkansas
    GREGORY W. MEEKS, New York           JEFF FORTENBERRY, Nebraska
    SHEILA JACKSON LEE, Texas
    LYNN WOOLSEY, California

                                C O N T E N T S

                                  ----------
                                                                       Page

                                   WITNESSES

    Peter Mugyenyi, M.D., Director and Founder, Joint Clinical
      Research Center................................................    11
    Joanne Carter, D.V.M., Executive Director, Educational Fund,
      RESULTS (also Board Member of The Global Fund to Fight AIDS, TB
      and Malaria)...................................................    19
    Ms. Debra Messing, Global AIDS Ambassador, Population Services
      International..................................................    28
    Norman Hearst, M.D., Professor of Family and Community Medicine
      and of Epidemiology and Biostatistics, Department of Family and
      Community Medicine, University of California, San Francisco....    33

              LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

    The Honorable Donald M. Payne, a Representative in Congress from
      the State of New Jersey, and Chairman, Subcommittee on Africa
      and Global Health: Prepared statement..........................     6
    Peter Mugyenyi, M.D.: Prepared statement.........................    14
    Joanne Carter, D.V.M.: Prepared statement........................    22
    Ms. Debra Messing: Prepared statement............................    30
    Norman Hearst, M.D.: Prepared statement..........................    37

                                    APPENDIX

    Hearing notice...................................................    56
    Hearing minutes..................................................    57
    The Honorable Christopher H. Smith, a Representative in Congress
      from the State of New Jersey: Prepared statement...............    58
    The Honorable Donald M. Payne: Statement of Ms. Vuyiseka Dubula,
      General Secretary, Treatment Action Campaign...................    63

        U.S. INVESTMENTS IN HIV/AIDS: OPPORTUNITIES AND CHALLENGES AHEAD

                                  ----------

                            THURSDAY, MARCH 11, 2010

                      House of Representatives,
              Subcommittee on Africa and Global Health,
                                  Committee on Foreign Affairs,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10:39 a.m. in
    room 2172, Rayburn House Office Building, Hon. Donald M. Payne,
    (chairman of the subcommittee) presiding.
        Mr. Payne. We will bring the meeting of the Subcommittee on
    Africa and Global Health to order.
        Let me first apologize for the tardiness of the hearing.
    There was a mandatory caucus meeting held on healthcare, which
    I had to at least attend for a few minutes. It is still going
    on, and that is why members over here are not present.
        I understand Mr. Smith was here, and I was waiting to see
    if he could return, since he was here on time initially. But we
    do have time constraints, so I am going to officially open the
    meeting. And when Mr. Smith comes, I will allow him to give an
    opening statement, even after we begin with the witnesses.
        So good morning again. Let me thank you for joining the
    subcommittee here today--the Subcommittee on Africa and Global
    Health. It is a critically important hearing, entitled U.S.
    Investments in HIV and AIDS, Opportunities and Challenges
    Ahead.
        In 2003, Congress passed the United States Leadership
    Against HIV and AIDS, Tuberculosis and Malaria Act,
    authorizing, at that time, an unprecedented $15 billion for
    global HIV/AIDS, TB, and malaria programs. This landmark
    legislation laid out ambitious goals: Prevention of 7 million
    new HIV infection, treatment of at least 2 million people, and
    care for 10 million people affected by HIV and AIDS, including
    orphans and vulnerable children.
        With courageous bipartisan leadership, PEPFAR quickly
    became the world's largest effort to combat a single disease in
    the history of mankind. In 7 years since Congress passed the
    original legislation authorizing the President's Emergency Plan
    for AIDS Relief, or PEPFAR, it has become a historic program.
        The word PEPFAR is known throughout Africa. This program
    will be remembered as probably the most significant achievement
    of former President George Bush.
        Prior to PEPFAR, the United States did not support any type
    of AIDS treatment abroad. Officials in the administration said
    that treatment was not feasible in Africa. One excuse that was
    used, as many of us remember, was said because Africans could
    not tell time, and therefore they would be unable to use the
    medication, and that we should simply limit our activities to
    the prevention of the spread of the disease.
        Then in 2008, Congress went even further, and PEPFAR won,
    to the amazement and surprise of many Members of Congress and
    the administration, and the world, when it reauthorized the
    program for another 5 years, at the additional level of $48
    billion, to prevent 12 million new infections, treat 3 million
    people living with HIV and AIDS, and care for 5 million orphans
    and vulnerable children.
        The bill also provided $4 billion to treat tuberculosis and
    $5 billion to treat malaria over the next 5 years. And it
    incorporated new and improved policy and programming mandates,
    including increasing the number of health workers in Africa,
    providing medicines for opportunistic infections, supporting
    nutritional programs, and removing some of the restrictions on
    funding to allow doctors and scientists to direct programming.
        PEPFAR programs have had a remarkable international impact.
    As of December 2008, approximately 4 million people in low- and
    middle-income countries were receiving anti-retroviral therapy
    (ART), about 10 times more than just 5 years ago.
        The number of new HIV infections among children has
    declined as a result of expanded access to medicine for the
    prevention of mother-to-child transmission (PMTCT). About 45
    percent of HIV-positive pregnant women worldwide had access to
    PMTCT services in 2008. This is a significant improvement from
    the 10 percent that we saw back in 2004.
        Increasingly, we are seeing the benefits of our AIDS
    response in other areas of the health sector, including
    improving vaccination coverage, family planning, strengthening
    laboratory and health systems, as well as decreasing infant and
    maternal mortality.
        Despite tremendous efforts made by the United States and
    the international community, AIDS is still among the biggest
    infectious killers the world has ever seen.
        Sub-saharan Africa remains the region most severely
    impacted by HIV and AIDS. Over 22 million people were living
    with HIV in Africa in 2008, and 1.9 million of whom contracted
    the virus during that year. About 1.4 Africans died of AIDS in
    2008, accounting for 72 percent of all the AIDS-related deaths
    worldwide.
        Although the rate of new infections is slowly declining,
    the number of people living with the virus continues to grow,
    due, in large part, to greater access to anti-retroviral
    medications.
        While coverage rates have improved across Africa, mother-
    to-child transmission continues to account for a substantial
    portion of the new HIV and AIDS cases. It is unconscionable
    that children continue to be born with the virus, when we have
    the tools to prevent transmission. We must make it our goal to
    eliminate mother-to-child transmission of HIV.
        I am deeply concerned about the reports that the fight
    against HIV/AIDS is faltering and continued rapid rollout of
    AIDS treatment is endangered in Africa. The economic crisis
    that has hit our nation and the world has also devastated the
    countries receiving our health aid, and calls for us to renew
    our efforts. And we must make sure that we don't start to
    decline.
        I certainly applaud President Obama's announcement of a
    broad Global Health Initiative (GHI) with a pledge of $63
    billion over 6 years. That includes $51 billion for PEPFAR, a
    $4 billion increase over the 2008 authorization, and $11
    million for maternal and child health, neglected tropical
    diseases, and an overall focus on building capacity of health
    systems.
        I look forward to working with the administration to make
    this vision a reality. I am especially pleased with the GHI
    emphasis, a focus on building the capacity of healthcare
    systems. I know that Dr. Goosby will ensure this initiative,
    and he will certainly continue to be a strong advocate in the
    fight against HIV and AIDS. And I don't think a more qualified
    person could have been selected for the very important
    position.
        At the same time, let us all remember that the advances in
    funding levels and reach of U.S. programs can be greatly
    leveraged through investment in national health systems. And we
    have seen that, but we have to know that we are strengthening
    health systems in other countries, so that when we do decrease
    funding, perhaps in the distant future, there will be strong
    health systems in those countries.
        In his 2010 State of the Union, President Obama addressed
    the reason for our efforts to fight HIV and AIDS: ``America
    takes these actions because our destiny is connected to those
    beyond our shores. But we also do it because it is right.''
        Despite our economic challenges, we must continue to reach
    out to other countries in need, not just because it is in our
    best interest, but because it simply is the right thing to do.
        I look forward to the continued evaluation of our efforts
    to combat this devastating disease, and I sincerely thank the
    panel of esteemed witnesses for testifying before us today and
    sharing their insights on what we, as a nation, should be doing
    and what more we can do to address this issue.
        Before I turn to the ranking member for his remarks, let me
    allow him to catch his breath. And let me also state that we
    look forward to having Dr. Goosby, the U.S. Global AIDS
    Coordinator, before this committee. Chairman Berman would like
    him to testify before the full committee at a later date, and
    ask that we hold off until he is able to do that. Therefore,
    this panel will only have a private panel. And at a future
    hearing, we will have administrative officials.
        And now I will turn back to Mr. Smith. I appreciate him
    being here earlier. I mentioned there was an emergency meeting
    that was called. I stayed just to be checked in, and came over
    then. But I am glad you are here again. Thank you.
        Mr. Smith. Thank you very much, Mr. Chairman. I want to
    thank you for calling this very important and very timely
    hearing to explore the future of the President's Emergency Plan
    for AIDS Relief, or PEPFAR.
        As you know, the Leadership Act originally passed with the
    sponsorship of Henry Hyde and Tom Lantos, and you and I and
    several others, but they were the lead; and was signed into law
    by President Bush, who initiated this historic health
    initiative in 2003, with very strong bipartisan support.
        It has been extraordinarily successful in countering the
    devastating toll that the HIV/AIDS pandemic was taking on, and
    is continually impacting women, men, and children throughout
    the world, most particularly in Africa.
        The United States' bilateral funding has provided
    lifesaving anti-retroviral treatments for over 2.4 million
    individuals--over half of the nearly 4 million persons
    receiving treatment in low- and middle-income countries. It has
    directly supported care for almost 11 million people affected
    by HIV/AIDS, including 3.6 million orphans and vulnerable
    children.
        Almost 340,000 babies have been born without HIV, even
    though their mothers were HIV-positive, thanks to PEPFAR's
    mother-to-child transmission prevention programs; and an
    incredible 29 million people have received PEPFAR-supported HIV
    counseling and testing.
        To achieve these results, as well as to make annual
    contributions to the Global Fund to fight AIDS, TB, and
    malaria, and related programs to treat tuberculosis, the U.S.
    has dedicated over $32 billion since 2004. The African people,
    who have been the prime beneficiaries, are well aware of the
    American taxpayers' generosity. During my travels to Africa I
    have been repeatedly overwhelmed with gratitude from people of
    all ages and walks of life, who credit George Bush and the
    American people and the Congress with saving their lives, their
    families, and their communities.
        However, Mr. Chairman, it is critical that we take this
    opportunity to step back and examine the best way to move
    ahead. As the title of this hearing indicates, there are
    significant challenges, as well as opportunities.
        One challenge is in respect to how treatment will be
    provided to new patients over the coming years. Estimates of
    the rate of new HIV infections, compared to those obtaining
    treatment, range from between two to one and five to one.
        While Congress authorized $39 billion in the 2008
    reauthorization, for 2009 to 2013, even this amount cannot
    fully cover the growing need. It is apparent that our country
    cannot carry this increasing burden, alone. I look forward to
    hearing our distinguished witnesses' proposals for resolving
    that dilemma.
        At issue with respect to PEPFAR, and I find this
    particularly disturbing, is the administration's proposed
    implementation of the so-called Prostitution Pledge. The
    purpose of this pledge, created to ensure compliance with
    PEPFAR, a PEPFAR mandate, is to prevent PEPFAR funding from
    being misdirected to those who refuse to oppose prostitution
    and sex trafficking as a matter of policy.
        Prostitution and sex trafficking exploit and degrade women
    and children, and exacerbate the HIV/AIDS pandemic. Yes,
    despite a clear statutory mandate based on an equally clear
    U.S. Government policy opposing prostitution and sex
    trafficking, the Department of Health and Human Services has
    issued a proposed rule that would substantially undermine that
    law and policy.
        It would create loopholes to allow not only affiliation,
    but shared facilities, staff, legal status, and bank accounts,
    as determined on a case-by-case basis between PEPFAR funding
    entities and entities that support prostitution and sex
    trafficking.
        As the prime author of the Trafficking Victims Protection
    Act of 2000, 2003, and 2005, I find this unconscionable.
        It would also significantly reduce the assurance that USAID
    is supposed to have that a PEPFAR-funded organization is in
    compliance with the relevant provisions of the PEPFAR
    legislation.
        Unfortunately, HHS has not yet posted, on the official
    regulations Web site, the comments that I have submitted
    strenuously opposing this proposed rule. And without objection,
    Mr. Chairman, I would ask that we make my comments a part of
    the record.
        Mr. Payne. Without objection.
        [The prepared statement of Mr. Payne
    follows:]Payne statement

        Mr. Smith. I appreciate that. My office is attempting to
    correct this omission, and I invite those concerned about the
    negative impacts of prostitution and sex trafficking in
    general, with respect to HIV prevention in particular, to read
    it. And we will have it at the desk, on the left, today.
        The HHS proposed rule is unacceptable, and should be
    rejected. If the proposed rule is promulgated, I can guarantee
    you this: I will leave no stone unturned in fighting it.
        I must also express my grave reservations with respect to
    certain aspects of the President's Global Health Initiative,
    which is otherwise an outstanding initiative.
        When the reauthorization of PEPFAR was being debated in
    2008, references to integrating and providing explicit funding
    authorization for reproductive health in relation to HIV
    programs in initial drafts were rejected. The term does not
    appear in the final legislation.
        However, the new GHI emphasizes the integration of HIV/AIDS
    programming with family planning, as well as various health
    programs. This is being undertaken--and this is the important
    point--undertaken in the context of a family planning program
    due to President Obama's recision of the Mexico City policy
    that now includes foreign non-government organizations that
    provide and support and seek the expansion of abortion.
        When one considers that this involves over $715 million in
    family planning funding alone in the 2011 proposed budget, the
    ability of abortion groups to leverage this funding in relation
    to HIV/AIDS under the GHI is deeply disturbing. This
    integration priority in my opinion is wrong.
        We are trying to prevent HIV/AIDS, not children. It is time
    to recognize that abortion is child mortality. Aborting
    dismembers, poisons, and starves to death a baby, and wounds
    their mothers.
        Let me remind members as well that goal number four of the
    Millennium Development Goals of the U.N. calls on each country
    to reduce child mortality, while at the same time pro-abortion
    activists lobby for an increase in access to abortion.
        It is bewildering, to me, how anyone can fail to understand
    that abortion is, by definition, child mortality. Abortion
    destroys children.
        Let me also point out that at least 102 studies show a
    significant psychological harm, major depression, and elevated
    suicide risk to women who abort. At least 28 studies, including
    three in 2009, show that abortion increases the risk of breast
    cancer by some 30 percent to 40 percent or more; yet the
    abortion industry has largely succeeded in suppressing these
    facts.
        Breast cancer in Africa, in many parts of Africa, is a
    death sentence. So-called safe abortion also inflicts other
    deleterious effects on women, including hemorrhage, infection,
    perforation of the uterus, and sterility.
        A woman from my own state of New Jersey recently died from
    a legal abortion, leaving behind four children. At least 113
    studies show a significant association between abortion and
    premature births. That is so under-focused upon, it is
    appalling.
        One example by Shah and Zao show that a 36 percent
    increased risk for preterm birth after one abortion, and a
    staggering 93 percent increased risk after two. And what does
    this mean for her children? Preterm birth is the leading cause
    of infant mortality in the industrialized world, after
    congenital abnormalities.
        Preterm infants have a greater risk of suffering from
    chronic lung disease, sensory deficits, cerebral palsy,
    cognitive impairments, and behavioral problems. Low birth
    weight is similarly associated with neonatal mortality and
    morbidity. Those facts are so under-reported upon, and I invite
    the press to look at those studies, and Members of Congress and
    members of our panel. Because we have, in Africa and elsewhere,
    as we have seen in the United States, designated or imposed on
    subsequent children born to women who abort a significant risk
    factor for a disability because of prematurity and low birth
    weight.
        So Mr. Chairman, the future of PEPFAR, and particularly in
    the context of the Global Health Initiative, has many, many
    challenges. And I look forward to exploring them with you. We
    have a consensus on PEPFAR. We have a consensus on so many
    aspects of global health, hopefully it does not get undermined
    by this emphasis on child mortality called abortion.
        Mr. Payne. Thank you very much. At this time we will, I am
    going to condense the biographical information I have before
    me. Normally I would go through much of the outstanding
    achievements, but I will, because of time, cut them short.
        I would like to introduce Dr. Peter Mugyenyi, who is the
    director and founder of the Joint Clinical Research Center in
    Kampala, Uganda, where he has served since 1992. In that role
    he leads the largest treatment initiative in Africa, funded
    through the U.S. President's Emergency Plan for AIDS Relief
    (PEPFAR). He certainly has collaborated with World Health
    Organization, National Institute of Health; has written books,
    including Genocide by Denial, and has a very outstanding
    resume.
        Next we will hear from Dr. Joanne Carter. She is executive
    director of the Educational Fund at RESULTS. She also serves as
    the board representative at the Global Fund to Fight AIDS, TB,
    and Malaria. Dr. Carter has worked with many of the world
    organizations, also. She is really one of the top advocates and
    does a tremendous amount of communicating throughout the world
    regarding the issue, and is a founding board member of the
    Global Acts for Children.
        Ms. Debra Messing is, of course, known for her role as
    Grace Adler, NBC's Emmy-Award-winning comedy series, Will and
    Grace. She won the 2003 Emmy Award, has earned a total of seven
    Golden Globe nominations. She is currently the Global AIDS
    Ambassador for Population Services International, and has done
    much travel, recently to Uganda, and does a fantastic job in
    advocacy.
        Finally, we have Dr. Norman Hearst, who is a professor of
    family and community medicine and epidemiology and
    biostatistics at the University of California, San Francisco.
    He has published many articles--over 70. Dr. Hearst has done a
    tremendous amount of research, and is one of the most respected
    professors in our nation.
        With that, we will start with Dr. Mugyenyi. We will have
    your testimony. Thank you.

    STATEMENT OF PETER MUGYENYI, M.D., DIRECTOR AND FOUNDER, JOINT
                        CLINICAL RESEARCH CENTER

        Dr. Mugyenyi. Thank you, Chairman Payne and Ranking Member
    Smith, for giving me the opportunity to address this meeting.
        PEPFAR has saved millions of lives in Africa. It started at
    a time when the AIDS crisis in sub-Saharan African had reached
    a catastrophic stage, because timely action was not taken, and
    the African countries were too overwhelmed by the sheer
    magnitude of the disaster.
        Before PEPFAR, less than 100,000 in Africa had access to
    lifesaving anti-retroviral drugs, and millions were dying from
    what had become a preventable death in rich countries.
        Today there are 4 million people on ARV treatment in low-
    and middle-income countries. These people, and their mothers,
    husbands, wives, and children, got a chance to live, more than
    half of whom have benefitted from the U.S. Government's
    contributions, PEPFAR and Global Front.
        Beyond treatment, support for current prevention efforts
    has helped ease the carnage that I and my fellow healthcare
    providers used to witness on a daily basis.
        Recently, recent evidence has shown that HIV programs,
    where they have reached community-wide coverage, have been
    among the most effective interventions, having impact well
    beyond the AIDS epidemic.
        Studies in Uganda have shown the increase in services for
    HIV/AIDS was accompanied by reduction in non-HIV infant
    mortality of 83 percent, as parents not only lived, but
    thrived. The DART study, which I co-chaired, found a 75 percent
    reduction in malaria associated with anti-retroviral therapy.
        These programs have also strengthened our health systems
    beyond addressing HIV/AIDS. For instance, PEPFAR assisted my
    institution to build the seven laboratories that support nearly
    all of the public clinics, and trained several thousand
    healthcare providers now providing crucial services to both the
    public and private sectors in Uganda.
        This success has been coupled with re-excitement and new
    evidence that reaching all of those in need of ARVs could help
    us stop new infections, and beat the epidemic for good. New
    data from the Conference on Retroviruses a few weeks ago, CROI,
    which I attended in San Francisco, show that HIV transmission
    between heterosexual couples in Africa reduce by 90 percent, if
    the HIV-positive partner is on treatment. This gives credence
    to the recent modeling by the World Health Organization that
    shows some of the first good news on prevention in several
    years, that we could truly end the AIDS crisis within a
    generation.
        Today, however, the crisis threatens to reverse. Today,
    however, the funding crisis threatens to reverse these highly
    positive changes, and we could miss the opportunity to defeat
    the epidemic.
        AIDS in much of Africa is still an emergency. It continues
    to be the biggest killer of women of reproductive age. In
    Uganda we have come very far, but we are less than halfway
    there.
        Unfortunately, over the last 2 years PEPFAR funding has
    flatlined. New PEPFAR contract awards emphasize treatment for
    only those already on it, and only very limited slots for new
    patients.
        Currently my institution, which pioneered anti-retroviral
    therapy in Africa and treats the largest proportion of AIDS
    patients in Uganda, is not taking all new patients, due to lack
    of funding. We are forced to turn away desperate patients
    daily, often 15 to 20. And most of those who come to us would
    have been turned away from a number of other clinics.
        When I say new, it is important to note that most of these
    are not truly new. Thousands of Ugandans, and millions
    throughout Africa, heard the message from PEPFAR that knowing
    the HIV status was important to protect yourself and others,
    and that treatment would be available to those who required it.
        Even though we have put thousands of patients on PEPFAR-
    supported care today, my program and numerous others across the
    country cannot deliver on the promise of treatment. I have
    witnessed many desperate patients unable to access therapy,
    including pregnant women, resorting to desperate and dangerous
    measures, including sharing out drugs with their family
    members, ignoring the good counseling advice they receive
    advising against this dangerous practice.
        Recently, an HIV-infection woman, who was breastfeeding her
    HIV-negative child because she could not afford formula milk,
    came to our clinic, having been turned away from other clinics
    in Kampal because they had no slots. She knew that every day
    she breastfed her baby without being on treatment greatly
    increased the chances of her child getting infected, but she
    had no alternative.
        We, out at JCRC in Uganda, led the ARV-resistant testing
    studies, which found that treatment interruption, including
    sharing of drugs, which is becoming increasingly widespread,
    result in drug resistance. This will result in large numbers of
    patients failing on simpler and low-cost first-line drugs, and
    needing more expensive and more sophisticated second-line
    therapy.
        We must end the forced dichotomy between the prevention and
    treatment. If we choose one over the other, we will fail. We
    must invest more strenuously in treatment, while also scaling
    up prevention programs, including male circumcision,
    combination prevention and services targeting high-risk groups.
        Let us also not forget that strengthening the health system
    and getting AIDS treatment to those who need it are not
    contradictory goals. We know from our experience in the 1990s
    that if treatment isn't there, people will not come to the
    health centers, and doctors will not stay.
        We know from our long experience that it is virtually
    impossible to have successful public health sector and AIDS
    programs, where some people get therapy and others in dire
    needs don't.
        The news of President Obama's new Global Health Initiative
    was received in Africa with great appreciation and enthusiasm.
    However, to ensure maximum health benefits, we must build in
    past successes, and ensure sufficient new money is available
    for successful integration of serious health issues. Otherwise
    we risk going back to the failed approaches of the 1990s that
    do not prioritize provision of lifesaving drugs.
        In conclusion, Mr. Chairman, allow me to refer to repeated
    commitments by United States universal access AIDS services in
    U.N. declarations, which caused great excitement and
    expectation in Africa.
        U.S., as the world's friend, came to the rescue of Africa
    at the time of our greatest need. It is our hope that current
    efforts can be strengthened, so that one day we can achieve our
    shared goal of a world free of AIDS.
        Thank you again, Mr. Chairman, for this opportunity, and
    the American people for their compassion and generosity. Thank
    you.
        [The prepared statement of Dr. Mugyenyi
    follows:]Peter Mugyenyi

        Mr. Payne. Thank you very much. Thank you.
        Dr. Carter.

        STATEMENT OF JOANNE CARTER, D.V.M., EXECUTIVE DIRECTOR,
    EDUCATIONAL FUND, RESULTS (ALSO BOARD MEMBER OF THE GLOBAL FUND
                     TO FIGHT AIDS, TB AND MALARIA)

        Ms. Carter. Chairman Payne and Ranking Member Smith, thank
    you so much for inviting me to discuss the opportunities and
    challenges ahead for U.S. investments in HIV/AIDS program.
        The House Foreign Affairs Committee, and particularly the
    members of this subcommittee, have been instrumental in
    crafting and supporting our U.S. AIDS response, with results
    that were almost unimaginable only a few short years ago. Both
    you and Dr. Mugyenyi referred especially to the massive
    treatment scale-up.
        And despite the clear bipartisan mandate of the Lantos Hyde
    Act, which, as you said, authorized $48 billion over 5 years,
    both to build on what has been achieved and to ramp up the
    response, there is unfortunately a significant gap between the
    vision expressed in that bill and its realization.
        So I would like to briefly review the funding situation we
    currently face, and then turn to some important opportunities
    to increase the impact of our response.
        The administration's Global Health Initiative calls for a
    more integrated, comprehensive AIDS and health response. It is
    a welcome intent, but it is only going to work if it is
    adequately funded.
        The President's Fiscal Year 2011 budget request essentially
    flat funds for our global AIDS programs, with just a 2 percent
    increase in bilateral AIDS funding, several billion short of
    what would have been needed to reach the Lantos Hyde
    authorization levels. And the budget actually proposes a $50
    million cut to the Global Fund to fight AIDS, TB, and malaria,
    and just a minuscule $5 million increase for bilateral TB, even
    though TB is the leading killer of people with AIDS.
        And as Dr. Mugyenyi has pointed out, flat funding actually
    means cuts to lifesaving services at the very moment when we
    built the capacity and the demand to get to the finish line,
    and at the very moment when the global economic crisis has
    profoundly exacerbated needs in Africa.
        I would like to highlight just three opportunities to
    fundamentally alter the course of the HIV/AIDS epidemic in the
    coming year.
        The first, again building on what Dr. Mugyenyi said, is to
    continue to scale up treatment, not just as a medical and a
    moral imperative, but actually as a public health strategy for
    reducing transmission of HIV. There is a growing body of
    evidence that widespread access to early treatment can help
    prevent transmission.
        And Congressman Smith, you raised the issue of, in a sense,
    the treatment mortgage, and the growing cost. But there is also
    both evidence and really exciting modeling that shows that if
    we are aggressive now on universal access to testing and early
    treatment, within not a very long time you actually break the
    back of the epidemic, and you start to see the curve going
    down. It just requires aggressive investment up front to make
    that happen. And we would be glad to share some more of that
    data with you.
        A second critical lifesaving opportunity is tackling
    tuberculosis. And both of you have really been leaders on this
    issue. It is the leading killer of people with AIDS. And as you
    know, an HIV-positive person who gets sick with TB is dead
    within a few weeks.
        Yet fewer than 4 percent of people with HIV/AIDS are
    screened for TB. This is the low-hanging fruit when it comes to
    saving lives, and we have yet to seize it. And people are now
    quite literally living with HIV because of ARVs and dying of
    TB.
        In just a few weeks the WHO is going to also reveal new
    data around the growing epidemic of drug-resistant TB. And
    despite successful pilot efforts, PEPFAR is still failing to
    take TB/HIV efforts to scale, and is essentially flatlining TB/
    HIV funding in Fiscal Year 2011.
        And the Global Health Initiative, as I said, proposes just
    a $5 million increase; but, perhaps more worrisome, it actually
    proposes targets for TB treatment scale-up that are much lower
    than actually what was in the Lantos Hyde Act.
        We actually know what to do about TB/HIV. We are just not
    doing it.
        And finally, I want to say we just have a tremendous
    opportunity to accelerate our global health efforts by
    increasing our support for the Global Fund to fight AIDS, TB,
    and malaria.
        I am honored to serve as the Northern Civil Society
    Representative to the Fund Board, and I would urge all of you
    to read the Annual Results Report released by the Fund just
    this week. Because I believe the Fund is the most effective
    tool we have in fighting these three diseases.
        The Global Fund has supported 2.5 million people on anti-
    retroviral treatment, 6 million treatments for TB, and the
    distribution of 104 million bed nets to prevent malaria. These
    efforts have saved an estimated 4.9 million lives through
    investments in 144 countries.
        I would just say that the success of the Fund is not just
    what has been achieved, but how it has been achieved; through
    an innovative, performance-based, transparent, multi-
    stakeholder process.
        One example. By focusing on value for money on all levels,
    the Fund has identified $1 billion in efficiency savings. And
    its impact has gone well beyond AIDS, TB, and malaria.
        Ethiopia has trained and deployed over 30,000 community
    health workers through Global Fun investments, with not only an
    astounding increase in AIDS treatment, but also rapid
    improvements in child and maternal health indicators, like
    measles vaccinations and births attended by health
    professionals.
        Civil society participation, as you know, is a prerequisite
    for the Fund, and 36 percent of grants are distributed to non-
    governmental organizations.
        And just on the funding issue. Importantly, the U.S.
    funding for the Global Fund has traditionally been matched two-
    to-one by other donors. Two-thousand and ten is going to be a
    critical year in determining the future of the Global Fund.
    Other donor countries will be making 3-year funding commitments
    as a part of the Global Fund's replenishment, and the
    President's proposed $50 million cut not only underfunds this
    hugely effective mechanism, but actually fails to exert any
    leverage on other donors.
        And just to, in conclusion, what is at stake. By 2015 we
    could virtually eliminate maternal-to-child transmission of
    HIV, eliminate malaria deaths in many endemic countries, and
    contain the spread of multi-drug-resistant TB. These are things
    we didn't dream were possible even a few years ago. And the
    Global Fund estimates that to maximize its impact will require
    about $20 billion from all sources for quality programs over
    the next 3 years. And a U.S. down payment would be about $1.75
    billion for 2011.
        If I can just end by saying sometimes it is difficult to
    articulate the profound impact our investments have had. But I
    wanted to share a story from my friend, Winston Zulu, who is
    the first person to go public on his HIV status in Zambia, and
    who lost all four of his brothers to TB.
        When I asked Winston the impact of the Global Fund and
    PEPFAR, he said something that I first didn't understand. He
    said now when I visit a village in Zambia, and I don't see a
    friend or a family member, I ask where they are. He said 10
    years ago in Zambia, if you went to a village and you didn't
    see someone, you never asked, because you assumed they died of
    AIDS.
        So just to say that our investments have done more than
    deliver drugs and diagnostics, this is nothing short of a
    transformation of despair into hope in an astonishingly short
    period.
        So I just am grateful for both of your leadership on this,
    and the leadership of this committee. We have made remarkable
    progress, and we can't stop now. And I look forward to your
    questions. Thank you.
        [The prepared statement of Ms. Carter
    follows:]Joanne Carter

        Mr. Payne. Thank you very much. We will now hear from Ms.
    Messing, who I mentioned was in Uganda recently, but I was
    thinking about Dr. Mugyenyi. It was Zimbabwe, I think, for your
    recent travels. I stand corrected. Thank you.

        STATEMENT OF MS. DEBRA MESSING, GLOBAL AIDS AMBASSADOR,
                   POPULATION SERVICES INTERNATIONAL

        Ms. Messing. Good afternoon, Mr. Chairman and members of
    the subcommittee. I am honored to join you today, representing
    PSI, a leading global health organization with programs
    targeting HIV in 55 countries, as well as programs in malaria,
    reproductive health, and child survival.
        I thank Chairman Donald Payne, Ranking Member Chris Smith,
    the distinguished members of the subcommittee and their staff
    members for organizing today's hearing.
        In 1993, at the age of 41, Paul Walker, my dear friend and
    acting teacher, died of AIDS-related complications. Paul's loss
    was devastating. After Paul's death I was moved to learn more
    about the epidemic.
        Three months ago I traveled to Zimbabwe with my colleagues
    from PSI, and with staff from UNAIDS, to learn more about the
    HIV pandemic in sub-Saharan Africa. What I saw in Zimbabwe was
    that the investment and strong support from PEPFAR, the Global
    Fund to Fight AIDS, Tuberculosis, and Malaria, and other
    donors, as well as the Zimbabwean Government, is paying off in
    dramatic ways.
        For example, Zimbabwe has experienced a reduction in HIV
    prevalence among adults from 29 percent in 1999 to 14 percent
    in 2009. But it also became heartbreakingly clear to me that
    resources still fall short of what is needed to reach everyone
    at risk for HIV.
        I would like to tell you today about two prevention tools
    that could make a difference, if there is continued investment.
    Male circumcision and HIV testing and counseling.
        First, voluntary adult male circumcision. There is now
    strong evidence, recognized by UNAIDS and the World Health
    Organization, that male circumcision reduces the risk of
    heterosexually acquired HIV infection in men by about 60
    percent. Yet only about one in 10 Zimbabwean adult men are
    circumcised.
        P.S.I and its partners run circumcision clinics in Zimbabwe
    and other countries, with support from PEPFAR and other donors.
        I was invited to observe the procedure, which is free to
    the client, completely voluntary, and, according to the young
    man I spoke with who underwent the procedure, painless. The
    cost of the procedure at that clinic, including followup care
    and counseling, is about $40.
        Even with no demand creation, the clinic I visited serves
    upwards of 35 clients per day. It is estimated that if male
    circumcision is scaled up to reach 80 percent of adult and
    newborn males in Zimbabwe by 2015, it could avert almost
    750,000 adult HIV infections. That equals 40 percent of all new
    HIV infections that would have occurred otherwise without the
    intervention. And it could yield total net savings of $3.8
    billion between 2009 and 2025.
        Many of the clinic's patients learn about male circumcision
    when they receive HIV counseling and testing at PSI's New Start
    Centers, and through its mobile outreach teams in Zimbabwe.
    Testing and counseling is the next area I would like to
    discuss.
        An estimated 72 percent of Zimbabweans with HIV are unaware
    that they are infected. To better understand the HIV counseling
    and testing process, I was tested for HIV at a PSI New Start
    Center in Harare that is funded by PEPFAR, the Global Fund, and
    the British Government.
        Despite the fact that I was confident of the results, I
    still felt anxious. In a pre-testing session, a counsellor
    talked to me and 10 other people about how HIV is transmitted,
    how to reduce risk, what happens if you test negative, what
    happens if you test positive; all bases were covered. And I
    felt my anxiety lessen, and I could see the same thing
    happening for those around me. Knowledge is power.
        A lab technician gave me the confidential test, a tiny
    pinprick to the finger. In a private room, a trained counsellor
    gave me my results after 15 or 20 minutes, and I felt a great
    sense of relief. I was counseled on staying negative.
        Had I tested positive, I would have been counseled on what
    that means. And I would have been referred to a post-test
    center, where I would receive additional counseling and
    referral services for anti-retroviral treatments.
        Thirty-five thousand Zimbabweans go through this HIV
    counseling and testing experience every month, as I did,
    emerging with a greater awareness of measures they can take to
    protect themselves and others.
        I saw firsthand that the U.S. Government's investment in
    HIV/AIDS is working. But although we have and utilize effective
    HIV prevention tools and strategies, like male circumcision and
    HIV counseling and testing, data from UNAIDS indicates that the
    epidemic continues to grow. Every day, 7,400 people become
    newly infected with HIV worldwide, and there are five new HIV
    infections for every two people put on treatment.
        In closing, I urge your ongoing robust support for PEPFAR
    and the Global Fund so that we can halt the spread of HIV, and
    comprehensively expand access to HIV prevention, care, and
    treatment. I am so grateful for the opportunity to brief you,
    Mr. Chairman, honorable members and colleagues. Thank you so
    much.
        [The prepared statement of Ms. Messing
    follows:]Debra Messing

        Mr. Payne. Thank you. Dr. Hearst.

       STATEMENT OF NORMAN HEARST, M.D., PROFESSOR OF FAMILY AND
       COMMUNITY MEDICINE AND OF EPIDEMIOLOGY AND BIOSTATISTICS,
      DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE, UNIVERSITY OF
                       CALIFORNIA, SAN FRANCISCO

        Dr. Hearst. Thank you. Good morning. That is a tough act to
    follow.
        It is an honor to be here. As someone who has worked with
    AIDS epidemiology and prevention for 25 years, I greatly
    appreciate this opportunity to share my thoughts about the
    future of PEPFAR.
        In my field, at least, I know that Congress can work
    together in a constructive and bipartisan way. PEPFAR has made
    a tremendous difference for many individuals and countries, and
    has done great things for the reputation of the United States
    in large parts of the world. Thank you.
        Nevertheless, PEPFAR today is at a crossroads, and faces
    new and difficult challenges. Some of these are results of
    PEPFAR's success; others are inevitable consequences of the
    mathematics of the AIDS epidemic.
        The last time I testified here was before the full
    committee, during the PEPFAR reauthorization hearings. The most
    contentious issue then was earmarks for prevention: Whether to
    require that a proportion of prevention funds go toward
    reducing the behaviors that spread HIV, as opposed to things
    like condoms and testing.
        At that time Tom Lantos, who had been my representative and
    for whom I voted many times, who was chairing the committee, at
    that time the main emphasis of my testimony was the solid
    scientific evidence behind the A and B of the ABC strategy for
    AIDS prevention: That is, abstinence, and be faithful, and to
    make clear that it wasn't just some sort of plot by the
    religious right.
        I am happy to say that Congress came up with a reasonable
    compromise on this issue. While ending rigid earmarks of
    spending for A and B, you required that PEPFAR programs in
    countries with a generalized AIDS epidemic provide a
    justification if they spend less than half of their prevention
    budget on A and B. Such justifications have now been submitted
    by some countries, and for the most part, they appear
    reasonable. The system is working.
        I don't know if anyone is pressuring you to revisit this
    compromise. If they are, I don't know what the problem is that
    they are trying to fix.
        But today I am concerned that PEPFAR's prevention efforts
    soon will be under an even greater threat than unfortunate
    ideological battles about how much to spend on promoting
    condoms versus encouraging people to stick to a single partner.
        The threat now is that prevention money may be syphoned off
    for treatment. As I said the last time I testified, we cannot
    treat our way out of this epidemic. What has happened since?
    PEPFAR is treating more people. But the number of people
    entering treatment is far less than the number of people
    getting infected, by somewhere between a two-to-one and five-
    to-one margin, depending whose numbers you believe.
        So despite all our efforts to rapidly scale up treatment,
    we are falling farther and farther behind. Funding for
    treatment cannot keep growing exponentially, and we now have
    many people on treatment whose virus is developing resistance
    to first-line drugs. This means they will require more and more
    expensive alternate drugs.
        Remember that we are not curing anyone. The people that
    PEPFAR treats have a lifetime entitlement to whatever drugs
    they need, unless we want to cut them off and let them die. So
    despite all our efforts to enhance efficiency and decrease unit
    costs, it is going to be increasingly expensive just to
    maintain the people we have on treatment, let alone to keep
    adding more.
        This is ironic, because we have worked so hard to encourage
    people to come in for testing and treatment. We have labored to
    create the demand for anti-retroviral treatment, and now we
    will inevitably find ourselves unable to satisfy that demand.
        Instead of being good guys for keeping millions of people
    alive, we seem to have set things up so that we will now become
    bad guys for turning people away.
        What we should be learning from the current situation is
    the paramount importance of prevention. What I am afraid will
    happen instead is tremendous pressure to divert the minority of
    PEPFAR funds going for prevention to treatment, so as to
    briefly postpone the day of reckoning, when we will have to
    admit we can't treat everyone. This would be a terrible
    mistake.
        There are people who will try to convince you that
    treatment somehow is prevention. They will tell you that
    prevention requires people to get tested, and that no one will
    get tested unless treatment is available. They will come up
    with complex mathematical models based on unrealistic
    assumptions to justify their assertions.
        Don't be fooled. Prevention is prevention; treatment is
    treatment. Any overlap is mostly wishful thinking in the
    African context.
        People promoting treatment as prevention in Africa ignore
    how HIV spreads in generalized epidemics. A large proportion of
    transmission takes place in early infection, when people's
    viral loads and infectiousness are highest, through networks of
    interlocking sexual partnerships, before people would even test
    positive, let alone enter treatment. How can treatment possibly
    stop that?
        Today we have many well-meaning people who want desperately
    to believe that treatment will work for prevention, but they
    have very little real evidence to show that it does. Instead,
    they offer theoretical models about how maybe it might work,
    and pretend this is evidence.
        The fact is that even in places like my hometown of San
    Francisco, where we have ideal conditions for so-called
    treatment as prevention, the evidence for whether it works is
    far weaker than people would have you believe. Yes, treatment
    can lower some people's viral load and make them less
    infectious, at least temporarily. But any benefit from this is
    probably overwhelmed by the negative effects of treatment on
    prevention. Once the general public knows that effective
    treatment is available, they worry less about AIDS and become
    riskier in their sexual behavior. We see this all over the
    world. My own research has shown this in places like Uganda and
    Brazil.
        What does work for prevention? Look at Uganda, the African
    country where I have worked the most. In the late 1980s and
    early 1990s, Uganda was Africa's greatest prevention success
    story. This was before HIV testing was available, long before
    treatment was available, and even before many condoms were
    coming into the country.
        But Uganda was able to cut its HIV infection rates by two
    thirds, simply by convincing people, on the average, to reduce
    their number of sexual partners. This was done with almost no
    donor funding.
        Now fast-forward to 2010. What is happening in Uganda? Most
    Ugandans have forgotten about reducing their number of
    partners, and instead internalize the foreign-donor message
    that prevention is really about condoms and getting tested.
    Furthermore, Ugandans who believe that effective AIDS treatment
    is available are now the very ones most likely to have multiple
    sexual partners. And rates of HIV are going back up again.
        I am not saying that treating people with AIDS is bad; I
    think it is great. If you can double funding for treatment in
    places like Uganda, I applaud you. But if you can't, PEPFAR
    needs to squarely face the reality of limits on how much
    treatment can be provided, and certainly not to raid the
    prevention budget to treat a few more people. Even if you
    double or triple funding, you will just have to face the same
    reality a year or 2 later.
        Facing reality is not easy. It means telling people in
    governments that we cannot bankroll unlimited treatment. We
    need to say, in a clear, unapologetic way, because we have
    nothing to apologize for, how much we can contribute.
        In Uganda and other African countries, treatment facilities
    are now turning away patients because the spots funded by
    PEPFAR and other donors are full. There was a recent cover
    story about this in the Wall Street Journal. It didn't help
    that Dr. Goosby was quoted as saying that PEPFAR will turn away
    no one who needs treatment. He may have been quoted out of
    context, but such statements will only breed resentment when it
    becomes impossible for us to make good on those words.
        We are now faced with flat funding to deal with an
    overwhelming and growing backlog of need. When the supply of
    treatment no longer meets demand, we will need to be especially
    vigilant about how scarce lifesaving treatment is allocated.
    Remember that many PEPFAR priority countries have tremendous
    disparities between rich and poor, between men and women,
    between the capitol city and rural areas. Many have poorly
    functioning governments and serious problems with corruption.
        We will need mechanisms to ensure that treatment funded by
    PEPFAR goes equitably to those who need it most, even in
    countries where nothing else is distributed equitably.
        PEPFAR already pays a great deal of attention to
    transparent and corruption-free financial management. But this
    will be a whole other challenge that will require specific
    monitoring.
        If any of my comments seem overly critical, I apologize.
    PEPFAR is a great program that has done great things in a short
    time, and about which all Americans should feel proud. But it
    now must grow up and recognize that it is not really an
    emergency program at all, and that we are in this for the long
    haul.
        We must be exceedingly wary of perceived open-ended
    promises that we cannot keep. We must base our efforts on
    reality, not wishful thinking. We must reject those who tell us
    that treatment is prevention, based on platitudes and
    unrealistic models. We must be clear and unapologetic about
    what we can and cannot do. And above all, we must not abandon
    the fight just because there are no easy solutions.
        Thank you.
        [The prepared statement of Dr. Hearst
    follows:]Norman Hearst

        Mr. Payne. Thank you very much. Unfortunately, there is a
    vote that has been called, so I will divide the time between
    three of us here, maybe about 4 minutes each. And because there
    is a series of six votes, I certainly cannot ask the panel to
    remain for that long a period of time.
        So let me begin by asking Dr. Mugyenyi, how would you
    evaluate, overall, the situation in Uganda? As we have heard
    early on, Uganda was discussed because of the tremendous
    problem. Then we saw the fact that Uganda really stepped up and
    had really aggressive programs, and we saw the increase level
    off, and even start to decline. Now they say there is, once
    again, a gradual increase.
        How would you characterize Uganda at the current time,
    maybe in a minute or two? And what you would suggest that we do
    to assist you, if we see things are in a negative mode?
        Dr. Mugyenyi. Thank you, Mr. Chairman. The situation in
    Uganda at the moment is quite worrying, for the simple reason
    that we are turning away patients. No provisions have been
    made, for example, for a pregnant woman. These pregnant women
    are turning up daily in various places. And the recent example
    is an HIV-positive pregnant woman who could not get treatment
    from several clinics because she is a new patient. We are not
    taking on new patients because the slots are few.
        Now, the testing that people who came for testing, Mr.
    Chairman, when we first started, and offered treatment, was so
    great that our clinics were swamped with people who wanted to
    know the actual status and the understanding that treatment
    would be available to them.
        Now, since the slots for treatment declined, our clinics
    can't go a day without anybody coming to offer testing. It is
    abundantly clear to us who are living on the ground in Uganda
    that treatment has been a great incentive for people to come
    for preventive services.
        Mr. Payne. Thank you, thank you very much. What we might do
    is that we decided that we will ask questions, and then,
    although we will have to leave, we would like for the questions
    to be answered in the time that we will allow the staff to
    listen to the answers, so it becomes a part of the record. And
    that way we can accommodate everyone.
        So I wonder, Ms. Messing, just a question. You became
    interested and involved in this area because of a person that
    you knew; and this issue, therefore, got your attention.
        I think that we need many, all levels of people, all walks
    of life interested in trying to work on education. And I just
    wonder if you have any suggestions on how we can get other
    people of your stature. We find that when we have people that
    have a lot of notoriety taking on an issue, it helps. And so if
    you have any idea of how we can, you know, get more associates
    of yours to take an interest like you have--that would be
    interesting to hear.
        And Dr. Carter, you know, in both the recent 5-year
    strategic plans for PEPFAR and the Global Health Initiative
    consultation documents, the U.S. Government states plans to
    better engage and leverage its relationship with multi-lateral
    partners, such as U.N. System and the Global Fund as a goal.
        How would you specifically encourage the U.S. Government to
    enhance those relationships? And how could the U.S. Government
    better harmonize its efforts with its multi-lateral partners?
        And just finally, Dr. Hearst, maybe you could give us a
    short synopsis of, once again, the priorities you would see,
    since you have indicated that we can't treat our way out. Too
    much is going for treatment and prevention efforts are lacking.
    Some ideas of how you would deal with that.
        And I will yield now to the gentleman, Mr. Smith.
        Mr. Smith. Thank you, Mr. Chairman. I have a number of
    questions, but I will narrow it to four, and look forward to
    reading or hearing your answers upon our return.
        I was at the U.N. Forum last year when Mr. Sarkozy and
    others made this real push for more mother-to-child
    transmission funding. And I wonder if all of you, or some of
    you, might want to comment on how inadequate or adequate our
    current funding level is in PEPFAR for mother-to-child
    transmission.
        Secondly, and Dr. Carter, this might be more a focus for
    you; when the Global Fund was first launched, all of us thought
    this is an idea whose time has come. But it was bypassing
    faith-based organizations almost systematically. The CCMs that
    have been established very easily can sidestep a faith-based
    hospital infrastructure.
        We know that in Africa, between 30 percent to 70 percent of
    the healthcare is under some religious auspices. It is a
    turnkey operation just waiting to be further utilized. I
    actually offered the Conscience Amendment, which passed only by
    one vote the first time in 2003, when we did the
    reauthorization when Tom Lantos was chairman. There was a broad
    consensus, and we had an excellent, solid conscience clause, so
    that certain faith-based groups that don't want to do certain
    kinds of prevention activities would not be precluded funding.
        What is the faith-based focus--we have met with Dr.
    Christoph Benn on a number of occasions to try to raise this
    issue. Please give us an update on that.
        Thirdly, very quick, Dr. Hearst, the Lancet had pointed out
    that the priority for adults should be B (be faithful),
    limiting one's partners; the priority for young people should
    be A (abstinence), or not starting sexual activity too soon.
    And that condoms, and you pointed out in some of your writings,
    and you had done a UNAIDS technical review, you said that when
    we look for evidence of public health impact for condoms in
    generalized epidemics, to our surprise, we couldn't find any.
    And you differentiated between generalized epidemics and a more
    focused one, a concentrated one.
        And finally, the IG's report--Dr. Carter, you might want to
    speak to this--some 48 percent of its recommendations had
    been--I know we are running out of time--had been not fully
    implemented by the time of the OIG's review. Your view as to
    how the Office of Inspector General is working. Because, you
    know, from an accountability point of view, a dollar wasted
    means a lost life.
        And we want, as we ramp up additional funding, we want the
    best impact possible, so good utilization of those dollars is
    important. Thank you.
        Mr. Payne. Thank you. Mr. Miller.
        Mr. Miller. Thank you. Dr. Carter, I know that you are
    familiar with the slum legislation that I introduced. And at
    risk of sounding single-minded, I think all of you are familiar
    with the number of studies and pilot programs that have
    documented a connection between secure, adequate housing and
    health outcomes. Certainly communicable diseases in particular,
    including HIV/AIDS, but also other chronic non-communicable
    diseases.
        But there doesn't seem to be much of a policy. And it
    appears not to just be a correlation that both inadequate and
    unsecure, insecure housing occurs in very impoverished
    societies; but there seems to be a causal connection.
        Do you see adequate housing programs as a health
    intervention for HIV/AIDS or other health conditions, for the
    prevention and treatment of HIV/AIDS? And do you think that
    there should be more of a policy focus on that as an approach
    to HIV/AIDS prevention and treatment?
        Mr. Payne. Well, thank you very much. What I will do at
    this time, first of all, I would like to put into the record
    that Mrs. Dubula, who is the General Secretary of Treatment Act
    Campaign in South Africa, had originally planned to testify
    before the subcommittee today, but unexpectedly fell ill.
        Therefore, I will ask unanimous consent that Mrs. Dubula's
    testimony be made part of the record. Hearing no objection, so
    ordered.
        Also, before members will have 5 legislative days to
    revisit and extend, revise and extend their remarks. And with
    no objection, we will now ask the panelists if you would be
    kind enough to answer the questions that were asked to you, in
    the order.
        And with that, we must leave to vote. Once again, let me
    thank all of you for coming, and we apologize, but we can't
    control what happens on the Floor. Thank you very much.
        And just technically, for the record, this hearing will
    continue for the purpose of getting answers to questions asked
    by the members. It therefore makes you official. Thank you.
        [Recess.]
        Mr. Payne. Well, it has been indicated that we will be
    unable to hear your questions, according to a ruling here, and
    that we may ask you to give us your answers in writing--and
    that the meeting will--we are trying to see whether there is a
    non-voting Member of Congress. We do have Mr. Eni Faleomavaega,
    who is chair of the Asia, the Pacific and the Global
    Environment Subcommittee, who is a non-voting member on this
    particular subject. And if he is available, then he could sit.
        Why don't we start responding? I guess Dr. Mugyenyi, would
    you like to begin your answer?
        Dr. Mugyenyi. Yes. Mr. Chairman, I was very concerned with
    Dr. Hearst's testimony, because the data that we are accruing
    in Uganda, and especially from my institution, which is closely
    involved with the HIV/AIDS since the early 1990s, clearly show
    that treatment is associated with strong incentives for
    prevention.
        So my submission today is that data which we have shows
    that that is what we have, right from our clinic, and the data
    that we have recently published. We followed up, we followed up
    3,400 severely infected patients with AIDS. And we found among
    those 340 babies were born. Not a single one among those was
    infected with HIV. And secondly, not any of the babies have
    been infected through breastfeeding.
        On maternal and child health, if we can provide PMTCT, we
    can prevent lots of pediatric infections. On the adults, we are
    finding that discordant couples, who are high-risk groups,
    perhaps the highest-risk groups, if you treat the infected
    partner, we are getting as high as a 90 percent reduction in
    infection. And then, very, very impressively, we find that if,
    in any clinic, you introduce treatment, people coming for
    testing just increase almost overnight. We have found opposite
    results in the clinics which do not have treatment. People just
    don't go for testing.
        Our studies are indicating that it is people who don't know
    their status who have no incentives to come for testing, who
    are contributing significantly to the continuing spread of HIV
    in our countries.
        I am not saying that prevention is not important. I am
    saying prevention and treatment, both of them are extremely
    important, and they need to be scaled up together. I would
    state quite categorically that without treatment, prevention is
    futile.
        Mr. Payne. Thank you. Dr. Carter, maybe you can respond to
    one of the questions. And Mr. Faleomavaega is on his way down,
    and then we will hear each of you answer one of them, and see
    if there are any remaining questions to be answered. Thank you.
        Ms. Carter. Yes, thanks a lot. One question you asked was
    about the GHI's intent to work more with multi-lateral
    institutions. And maybe I will just say a few quick comments
    around the Global Fund. I mean, just to say that given that the
    Global Fund is providing about two thirds of the external donor
    funding for tuberculosis and malaria, it is actually a key
    back--and a quarter of AIDS funding--it is a key backbone for
    U.S. efforts.
        And if you talk to the President's malaria initiative
    folks, but also as far as TB, and certainly a really important
    partner on HIV/AIDS. And again, I think really complimenting
    each other in a sense that PEPFAR has certainly been more
    focused, but the Global Funding and working in 144 countries
    has got that breadth of efforts that is kind of complimenting,
    but also filling in many of the gaps that PEPFAR is not
    reaching.
        I think, as you are aware, PEPFAR is also providing
    important technical support and technical assistance to help in
    the implementation of Global Fund grants. And that is actually
    an important role.
        And I would say there is a few lessons that are being
    gleaned from the Fund with regards to value for money. Like how
    do we reduce commodity costs, how do we actually benchmark the
    cost of quality interventions, like what does it cost to
    deliver AIDS treatment, what does it cost to deliver prevention
    in certain areas. And benchmarking some of those in a way that
    I think can benefit not just the Global Fund, but kind of all
    of our initiatives, and helping us find efficiencies on that.
        So those are just I think some of the ways that PEPFAR can
    partner with, but also, I mean, in a very substantive way, but
    also in a kind of aid-effectiveness model with the Global Fund.
    And it is quite important.
        Mr. Payne. Yes.
        Ms. Messing. Mr. Chairman, you asked how I could help bring
    attention to my peers in the Hollywood community, or other
    public people, so that they can help support this effort. I
    will commit to engage my peers in Hollywood.
        What I would like to say is that I think what is an even
    more powerful strategy is to involve young people in the
    political process; to build leaders among our youth. I am so
    glad to see so many young people here today. I came a little
    bit late to the process.
        And I would also like to say that it is, I believe that it
    is part of our DNA, as Americans, to help, regardless of where
    it is. That has been proven with our reaction to the Haiti
    crisis, and I think it is our moral imperative.
        So I think that you can get people from--I am sorry.
        [Pause.]
        Ms. Messing. I think that people in my community like to
    stand behind things that they know work. And the efforts that
    the U.S. Government has made, the investments that they have
    made in HIV prevention have been proven to work.
        And it has been good works, so far. We just need to
    increase the funding for prevention, so that the good works can
    help more people.
        Mr. Faleomavaega [presiding]. I believe the question has
    been raised for all the members of the panel to respond to. And
    I want to thank Ms. Messing for her response.
        And I believe Dr. Hearst may have a comment on this
    question, as well.
        Dr. Hearst. Yes, thank you. They were kind of a series of
    questions thrown out, and I will try to kind of weave them
    together and address as many of them as I can.
        I was asked what I would suggest the priorities would be,
    and what we should do. Even though I am someone who has worked
    in prevention mainly, and would love to see more resources
    going to prevention, I am not here making a pitch to increase
    the proportion of PEPFAR funding going to prevention. I think
    PEPFAR probably has the mix about right. And there is a
    tremendous need for treatment, and I am not arguing that that
    should be cut back.
        All I am saying is let us not cut back prevention when we
    see this tremendous need in demand for treatment in front of
    us. And in the prevention area, my priorities would be to
    invest the money on what has worked; that is the ABC strategy.
    And now what is new in the last few years is the increasingly
    good evidence behind male circumcision, which you have just
    heard from Ms. Messing, as an effective, cost-effective
    intervention that actually there is a great deal of interest
    in. And we need to make sure that that is available to anyone
    who wants it, in an easy and affordable fashion.
        When I say I support the ABC approach, I support all three
    parts of it. But, as Mr. Smith was alluding to, in generalized
    epidemics it seems to be the B of the ABC that makes the most
    difference. You have got to get people to limit their number of
    partners, to stick to one partner, if not for a lifetime, at
    least one partner at a time.
        It seems to be these networks of overlapping, ongoing
    relationships that, if one person in there gets infected, the
    whole thing goes up in flames, so to speak. At least the
    research I have seen, Africans don't have any more--the number
    of sexual partners they have in their life isn't any higher
    than Americans or Europeans. But there seems to be, at least in
    some countries, more of these ongoing overlapping
    relationships, as opposed to the more serial monogamy we have
    in the U.S. I am not saying one is better than the other or
    worse than the other; it is just that the one facilitates the
    spread of HIV more. We need to break up these networks of
    multiple partnerships. That is what really makes the most
    difference.
        And which really, when you get down to it, has nothing to
    do with testing. You will keep hearing, we have got to get
    testing, people have got to come in for testing to do
    prevention.
        Testing is great. It has nothing to do with prevention.
    Being tested doesn't prevent a single infection. It only
    prevents infection if it then leads to changes in behavior.
        So as Ms. Messing was describing, she comes in and tests
    negative; they tell her use condoms and stick to one partner.
    If she had tested positive, they would tell her use condoms and
    stick to one partner. The message is the same. You don't need
    testing to do prevention. You do need testing to do treatment.
        I was asked, or we were all asked about mother-to-child
    transmission. Again, I think PEPFAR probably has the mix of
    funding about right. Mother-to-child transmission is a very
    appropriate target for our prevention efforts, because it is a
    moral imperative. We want to protect the most vulnerable, who
    certainly are infants. And it works. So it is a good place to
    invest our resources in that sense.
        However, I have to qualify that a little bit, as an
    epidemiologist and looking at the public health perspective, to
    say that as important as it is, it doesn't really have much of
    any impact on the epidemic. Why? Because preventing
    transmission to babies is wonderful and an imperative and all
    that, but those babies wouldn't be transmitting the virus to
    anybody else, at least not until they grow up and survive into
    adolescence or adulthood. So they are sort of an
    epidemiological dead end. They are very important as human
    beings, but unfortunately less important, epidemiologically
    speaking, because they wouldn't transmit to others.
        I was asked about, we were all asked about housing and
    poverty, and the relation to AIDS. And I think it is very
    important that we think of, that people need housing. I think
    it is a crime sometimes that the West will spend, and us, will
    spend thousands of dollars a year so that they don't die of
    AIDS, but who cares if they live in abject misery. And I think
    that is a real contradiction.
        However, in the field of HIV/AIDS, unlike tuberculosis and
    many other diseases, there is no clear relation between income,
    poverty, and HIV/AIDS. In fact, in most African countries, HIV/
    AIDS rates are actually higher among those who are relatively
    better off.
        So I think we need to do poverty alleviation because we
    need to do poverty alleviation, but really, we shouldn't fool
    ourselves into thinking that is AIDS prevention. Rich people do
    not have fewer sexual partners than poor people. In fact,
    particularly among men, they tend to have more partners. And
    that is what spreads the epidemic; it is having multiple
    partners, it is not being poor.
        I think that touched on most of the questions that were
    asked. Thank you.
        Mr. Faleomavaega. I don't know if a question was raised by
    members who were here previously, but just wondering, you know
    when HIV/AIDS first came about, the stigma attached to this
    illness was so negative, even when it touches on the gender.
        And I wanted to ask the members of the panel if America has
    gone past that. If you are associated, or if you have HIV/AIDS,
    not only isolation, but they put you as something, almost
    classify you as someone who is immoral. And I was just
    wondering if members of the panel, what is your take on what
    seems to be the sentiments of members of our society,
    especially here in this country. I don't know how it compares
    to Africa. But I would be very curious.
        Ms. Messing?
        Ms. Messing. Well, I can't speak to the specifics of the
    United States. But what I can tell you is what I saw and
    experienced in Zimbabwe, and at the New Start clinics that are
    part of the U.S. investment.
        There is a focus on instilling hope, and empowerment to the
    people who have been diagnosed positive. I met with people who
    were positive, who were graduating from a long series of
    sessions, learning how to live positively. And I can tell you
    that whatever stigma there is--and there is a stigma there, as
    well--that the prevention efforts address that.
        And if I may, I would just like to respond to Dr. Hearst,
    and say that in my travels in Zimbabwe, I saw firsthand the PSI
    programs at work. And they target reduction of concurrent
    sexual partnerships. That is a, one prong in a multi-pronged
    attack, which includes condoms, testing, counseling, male
    circumcision, delaying sexual debut.
        I sat with a boy who was the first person to get
    circumcised in Zimbabwe, 18 years old. And he had never been
    sexually active prior to it. And he told me that through his
    counseling, he had determined that he was going to delay his
    onset of sexual activity.
        And I sat with people who had gone through the HIV testing
    process, and I sat alongside people who were counseled. And
    they told me that the information that they had gotten from the
    New Start clinic had made them change their behavior regarding
    sexuality.
        So to say that just condoms or just testing, it is so much
    more than that. It is, it is a comprehensive approach. And it
    is working.
        Dr. Mugyenyi. Yes. Perhaps I could----
        Mr. Faleomavaega. Dr. Mugyenyi.
        Dr. Mugyenyi. Yes. Perhaps I could take you inside Africa,
    and say that stigma was at its highest because people, among
    other things, feared death. You test positive, you are going to
    die.
        Now, when treatment came, you test positive, you are not
    going to die; you are going to get treatment.
        Stigma, particularly in a country like South Africa, has
    been declining. And the driver for the decline in the stigma
    has been availability of life-saving treatment.
        There has also been a referral to testing. When you test,
    obviously you are not treating, you are testing. But people who
    come in such big numbers for testing, what do they get? They
    have come, they have presented themselves to a point of care.
    And when they present themselves to a point of care, it gives
    us great opportunity to give them risk-reduction messages. This
    is where we tell them about male circumcision. This is where we
    tell them about condoms. This is where we tell them about being
    faithful, the B that is being mainly applauded by faith-based
    organizations. This is where we do all of those.
        And it is through those kind of initiatives, where
    treatment is available, that we have been able to expand our
    operation. My organization has been able to expand 75 different
    places all over the countries, all over the country in Uganda.
    And everywhere we go, people are attracted. They know they are
    not going to test and be told the sad news today you are going
    to die. The clock has started ticking today. We give them the
    good news, if we find them positive, the good news that we will
    treat you, and what we require of you is to protect others
    against AIDS.
        Lastly, Mr. Chairman, there was another point about
    prevention of mother-to-child. There is a moral imperative
    here. Prevention of mother-to-child works wonderfully. It has
    almost terminated childhood AIDS that is transmitted from
    mother to child in rich countries, including the United States.
        In our countries, it is still a very big problem. So people
    support it because its effects are quite obvious.
        But what do the moral imperative I am talking about, Mr.
    Chairman, is that currently we are giving prevention to the
    mother, treatment or prevention to the mother, so that the
    child can be born HIV-free. And then we let the mother die. She
    is a new patient; she can't get treatment. It is a moral
    imperative.
        There has not been any provision that has been put in the
    PEPFAR, with flat-lined budget, that mothers will be treated.
    It is a particular imperative in Africa because the majority of
    the people who are living with AIDS, who are coming for
    testing, who are actually getting infected today, they are
    women. This is the moral imperative that we have.
        Mr. Chairman, in 1990s the messages we were being told were
    that AIDS treatment was impossible in Africa. We are being told
    that prevention was the only thing that Africa needs. I am
    shocked to hear it this time, when it has been abundantly
    illustrated that treatment is possible in Africa, and data is
    coming out quite clearly, and it is showing that we can break
    the back of this epidemic by strengthened efforts on
    prevention, as well as strengthened efforts on treatment.
        So Mr. Chairman, this is a critical time for us in Africa.
    And we hope these points are taken in account. And we do not
    get people who take us back to the dark ages of 1990s, when all
    of this was said to be impossible.
        Mr. Faleomavaega. I would like to ask Dr. Carter, I have
    one or two questions. Did you want to comment on them?
        Ms. Carter. I wanted to just again, building on the point
    about prevention of maternal-to-child transmission, a couple of
    things.
        I was talking about funding needs. The Global Fund has
    actually looked at what it is going to take. And by 2015, we
    could literally eliminate this vertical transmission from
    mother to child.
        If the Global Fund was fully funded at the highest-end
    scenario, it could actually cover some 75 percent of that need.
    If you then add what the Global Health Initiative could do, we
    could actually cover 100 percent, and we could achieve
    essentially ending vertical transmission.
        I would just also say to build on Dr. Mugyenyi's point, is
    that it is both a moral imperative, but it is also, you know,
    these children are born, when they are born without HIV. So
    what are the most important markers for their survival?
        One is to be born without HIV, the second to have a mother
    who survives. So the importance of both of those things is
    absolutely key.
        And then just a couple of other, maybe I will comment on
    one other question, and then I will come back. I want to come
    back to Congressman Smith's questions about the Global Fund.
        But just on the question around the issue of slums, I would
    only say obviously links between housing and issues like
    tuberculosis, and housing and issues like stress. But I think
    there is also the issue of the degree to which economic
    situations create vulnerabilities for people which then put
    them at risk, both physically, but also socially and
    economically, for these diseases.
        So I think a hugely important issue about just the economic
    situation, that families, in particular women, find themselves
    in. And that certainly includes housing, but the overall
    situation that they are surviving in.
        Mr. Faleomavaega. You caught me on that. I was going to ask
    you to give us an update on the Global Fund, including faith-
    based organizations; and also your opinion of whether or not
    the Inspector General's recommendations are taken seriously by
    the Global Fund Secretariat. Can you respond to that?
        Ms. Carter. Yes, I can, and I very much want to. I think,
    first on the issue of faith-based organizations, the data that,
    the best data that we have that is compiled shows that nearly
    80 percent of the country-coordinating mechanisms that are
    requirements for the Global Fund for countries to be able to
    put forward grants, have at least one representative of the
    faith-based community.
        And we know that it is, the data is probably better than
    that, and I will come back to that, because they are compiling
    new data. But that is the data we have as of a couple of years
    ago.
        Also, what we will note is that the percentage of funding
    going to faith-based organizations as the principal recipients
    of Global Fund money and as sub-recipients is highest where
    they play the biggest role in health-care delivery. So just for
    example, in Western Central Africa, faith-based organizations--
    again, and this data is a bit outdated. It is better now, but I
    can give you this.
        In Western Central Africa, about 12 percent of funding; in
    Latin America, in the Caribbean, about 11 percent of the
    funding. And just to note that there have been new and major
    grants to faith-based organizations, including its principal
    recipients in Round 8, to a broader range of them, and some
    large grants to faith-based organizations in DRC, in South
    Africa. And the Global Fund is updating a study, and we will
    have that by the end of this year, which will include data from
    Round 8 of grants and Round 9, on faith-based organizations.
        And I would say just having been involved in a number of
    gatherings of civil society organizations, there has been a big
    focus on how do we actually increase overall the role of civil
    society, including through dual-track financing. Which, I do
    not know if you are familiar with, but since Round 8 the Global
    Fund has actually been really pushing to have two principal
    recipients of grants, for grants, one governmental, one non-
    governmental. And also really a productive push at looking at
    the role of faith-based organizations, especially again where
    they are a big proportion of service delivery.
        On the Inspector General for the Global Fund, just a
    couple, again a couple of broad points, and then a more
    specific answer to your question.
        So the Inspector General operates independently of the
    Secretariat. It reports directly to the Board. The Inspector
    General's reports are required to be posted on the Web within 3
    days of providing them to the Board.
        There is an enormous amount of transparency on the part of
    the Global Fund around these things. In some ways I think the
    Global Fund can sometimes suffer just by the level of
    transparency, which I think, you know, is not met by most other
    aid agencies. But it is some important things.
        The Inspector General's budget has doubled between 2008 and
    2009. The office is now a 12-person team with a wide network of
    experts that they can contract, if needed. And this has really
    allowed for robust investigative capacity.
        And in addition to providing an anonymous hotline for
    complaints, the IG is now also proactively identifying high-
    risk countries based on transparency, international indices, so
    they can be more closely monitored.
        I know the Board is really very engaged in this. I think if
    there is a slight lag time sometimes in implementing all of the
    IG's recommendations, I think there is transparency about that,
    too. But the Board takes this very seriously. The Fund takes it
    seriously, the Secretariat does.
        It is clear that the Board, by doubling the funding for the
    Inspector General's Office, is wanting to actually strengthen
    and increase this function. So, and the Global Fund has a very
    strong Inspector General. So I feel actually very positive
    about the direction that this is going.
        Mr. Faleomavaega. Not taking anything away from Africa, but
    I wondered if any of you would comment about the two most
    populous nations of the world; mainly, China and India, and
    Asia for that matter. Because I am positive that HIV/AIDS is
    just as serious, in terms of what is happening in that region
    of the world.
        Does anybody care to comment on that?
        Dr. Mugyenyi. Yes, Mr. Chairman, if I may just make a brief
    comment.
        Mr. Faleomavaega. Please.
        Dr. Mugyenyi. Because AIDS is an insidious disease if it is
    being ignored. And if there is compressence, that is what
    happens. We have huge populations in Asia, especially China and
    India, and a very small percentage increase means huge numbers
    in those countries.
        And there is a bit of compressence which was there. And
    AIDS was spreading insidiously. It is the same situation that
    we are seeing and we are worried about. AIDS was allowed to
    spread in Africa.
        For example, in South Africa, which is the highest
    incidence country, with over 5 million people living with AIDS,
    at the time when Uganda had the highest peak, South Africa had
    very low. In some of the areas, it was as low as only 1.5
    percent. But no action reactivated this disease.
        And so the fear is that if the AIDS in Asia, those huge
    populous countries, is not taken seriously, small percentages
    means lots of people. And AIDS is unforgiving if action is not
    taken. And it needs continuous awareness, as we need, even at
    this stage where we are in Africa. We can't afford to ignore
    it. It is not going to stop; it is going to keep growing. And
    things will not become any easier; they will become more
    complicated.
        And in Africa, we are now trying to prevent catastrophes of
    need for second-line drugs. And need for second-line drugs, if
    stop the sharing out drugs, those who are using them, and stop
    people not taking proper dosages. Because if resistance happens
    in Africa, if we don't take action now to make sure that access
    to treatment is available, people are going to misuse drugs.
        Because you can't hide the fact that drugs are available.
    They are already aware. So all they can do, if we don't give
    them support, is misuse them, with the consequence of
    resistance happening at public sector level; and also making
    the HIV complicated, HIV epidemic much more complicated, and
    much more expensive to manage in the future.
        In Asia and in Africa, we need not to relax, but to
    continue all of the efforts. It needs more funding,
    unfortunately, even when there is a recession. AIDS
    unfortunately does not go in a recession.
        Mr. Faleomavaega. If I may, the members of the panel, if
    you have any concluding statements that you would like to make,
    as I am sure members of the committee may want to submit
    further questions to each of you. It will be made part of the
    record if you would like to do that.
        So I would like to give you parting shots, or the best that
    you could relate to our hearing this morning. Dr. Hearst.
        Dr. Hearst. I don't know if this is really a parting shot,
    but I wanted to address your question about Asia. And I think
    the point was made that even if prevalences are low, that
    populations are so large it can add up to a lot of people.
        I think we have to remember always in our thinking about
    AIDS and how to respond to it, this key difference between
    countries with concentrated epidemics and with generalized
    epidemics.
        The generalized epidemics have only occurred in a few
    countries, mostly in sub-Saharan Africa, for reasons that we
    don't completely understand, but are now understanding better,
    when the conditions are right to have spontaneous transmission
    and a growing epidemic within the general heterosexual
    population.
        I like to tell students to think of it as if you are in a
    grassland, and somebody is throwing matches out there. If the
    grass happens to get just dry enough, the whole thing will go
    up in flames. Otherwise you will get a little smoldering there,
    and that will be it.
        And that is sort of the same thing, with the transmission
    dynamics, in a generalized, as opposed to a non-generalized,
    epidemic.
        Fortunately, there are no generalized epidemics in Asia,
    except maybe Papua New Guinea, and there never will be. AIDS
    has been around long enough that anywhere that there is going
    to be a generalized epidemic, it would have already happened.
        That doesn't mean there is not a serious problem. In China
    there is a serious problem mainly related to injecting-drug
    use.
        Mr. Faleomavaega. Dr. Hearst, when you say generalized
    epidemic, what do you mean by that?
        Dr. Hearst. I mean an epidemic that is self-sustained in
    the general population of people who do not belong to any
    particular high-risk group.
        Unlike the epidemics in the U.S., in every rich country in
    the world, and in fact in all but about a dozen countries of
    the world, although those dozen are very important because they
    account for more than half of all AIDS cases in the world, you
    don't have these conditions for generalized spread. So though
    you get infection transmitted in certain high-risk groups--men
    who have sex with men, injecting-drug users, in Asia commercial
    sex, very important, the sex industry, the clients.
        And then there are a few unlucky people, victims or
    whatever you want to call them, who get infected by someone who
    is in one of these groups. But the point is they don't, on the
    average, you have to have each person on the average infecting
    more than one other person for it to become self-sustaining.
        So it stays in these concentrated groups. A few others get
    infected, then they infect fewer, it smolders out. That doesn't
    mean that there aren't millions of people infected in India,
    but it is not a generalized epidemic. And if it was going to
    be, it would have been already.
        Mr. Faleomavaega. So what makes Papua New Guinea in that
    classification as a generalized epidemic?
        Dr. Hearst. I have never been there or worked there. But
    from what little I know about it, it probably has to do with
    patterns of sexual behavior more than anything else.
        Mr. Faleomavaega. Papua New Guinea has about 7 million
    people, and about three to four hundred tribes. And each of
    those tribes speak different languages. So I was just curious
    when you mentioned that. I have a little familiarity with that
    part of the world. I was just curious.
        Dr. Hearst. Well, you are more familiar than I am, so I
    shouldn't really speculate on that.
        Mr. Faleomavaega. Besides Papua New Guinea, are there other
    countries in the same category?
        Dr. Hearst. Not in Asia, there are not other countries with
    generalized epidemics. And that, in a way, has made it easier
    to respond.
        For example, in Thailand, it was mainly related to sex
    work; also to injecting-drug use. So they can, you can get very
    high rates of condom use in the brothels. Cambodia, too. And
    you can bring down the infection rates very successfully, like
    they have done.
        Mr. Faleomavaega. Ms. Messing.
        Ms. Messing. Thank you, Mr. Chairman. I just want to thank
    you for having me here today. It is an honor to be able to
    speak as a part of this hearing.
        And I just want to reiterate that the U.S. Government's
    funding for HIV prevention is working. I saw it firsthand in
    Zimbabwe. It is a success story. And I just encourage the
    United States Government to continue their robust support of
    PEPFAR and the Global Fund, so that the success can be built
    on, and we can bring a halt to the spread of HIV. Thank you.
        Mr. Faleomavaega. Well, as our Good Will Ambassador, I
    think we could not have selected a better person than you, Ms.
    Messing, for doing this. I deeply appreciate your service and
    your commitment in helping resolve this very serious problem in
    the world. Thank you.
        And thank you. We are honored by your presence of being
    here this morning. Thank you very much.
        Dr. Carter.
        Ms. Carter. Thanks very much. I am going to just quickly
    reiterate a couple of the points I made at the beginning. I
    mean, just to say again among the opportunities we have,
    aggressively addressing TB, HIV, and supporting TB programs,
    the low-hanging fruit for saving lives in terms of people with
    HIV.
        Second, that the Global Fund is an enormously important
    mechanism for AIDS, but also for TB and malaria, and for
    broader impact in maternal and child health; and it leverages
    other donor resources, and lots of lessons to learn from how it
    works, so I think really important.
        And I guess the last thing I would say in terms of what
    sort of ended up on this panel as I think a bit of a debate
    around prevention and treatment, I want to say I think part of
    where that is coming is this feeling that the challenge of
    fighting over what looks like a pie, unlimited pie that can't
    be expanded.
        And I want to say this committee and the work that has been
    done here changed the reality of what was possible around HIV/
    AIDS, and really created a new reality and how we are seeing
    this.
        I think we all support, absolutely support, the aggressive,
    the need for aggressive prevention. We have talked about PMTCT,
    we have talked about other really critical prevention. My own
    organization supports access to education for children,
    especially girls in Africa, because of its prevention effects,
    among other things. So I think we all support that.
        I think what we are also saying is that treatment can have
    important impacts on prevention. You know, and that the good
    news is if we can aggressively scale up treatment, there are
    models that do suggest that we could actually bend the curve.
    But it will take aggressive treatment and aggressive prevention
    to do that.
        And so, you know, I guess my message is this is working,
    you guys have led on this, the U.S. and the U.S. Congress has
    led on this. And we can't give up now. We actually have to
    increase the resources so that we can do both, and basically
    bend the curve down. Thank you.
        Mr. Faleomavaega. Thank you, Dr. Carter. Dr. Mugyenyi.
        Dr. Mugyenyi. Thank you, Mr. Chairman. Like Dr. Carter, I
    want to conclude on that note. We need continued support so
    that we can build on the clear successes of PEPFAR, which it
    has achieved.
        And if we build on those successes that are quite clear,
    that are commented by virtually everybody who has access to the
    program, we can treat our way out of the epidemic. Not only
    with the treatment by itself. We can clearly treat our way out
    of this epidemic if we accompany it with the robust new
    preventive initiatives. Actually, there is not any other way
    with such a vicious epidemic, other than to scale up treatment
    and support robust preventive initiatives.
        Thank you, Mr. Chairman.
        Mr. Faleomavaega. Well, I certainly want to say that on
    behalf of my colleagues and the committee, to thank all of you
    for taking the time from your busy schedules, and coming here
    to testify, sharing with us your expertise and understanding of
    this important issue.
        Again, thank you so much for coming. The committee stands
    adjourned.
        [Whereupon, at 12:23 p.m., the subcommittee was adjourned.]

                                A P P E N D I X

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         Material Submitted for the Hearing Record Notice

    [Note: Material submitted for the record by Mr. Smith, HHS Proposed
    Rule: Organizational Integrity of Entities Implementing Leadership Act
    Programs and Activities, 74 FR 61096 (23 November 2010), is not
    reprinted here but is available in committee records.]