[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.]






                                 
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