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


 
 PEPFAR: FROM EMERGENCY TO SUSTAINABILITY AND ADVANCES AGAINST HIV/AIDS

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


                                HEARING

                               BEFORE THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 29, 2010

                               __________

                           Serial No. 111-129

                               __________

        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
THEODORE E. DEUTCH,                  CONNIE MACK, Florida
    FloridaAs of 5/6/       JEFF FORTENBERRY, Nebraska
    10 deg.                          MICHAEL T. McCAUL, Texas
JOHN S. TANNER, Tennessee            TED POE, Texas
GENE GREEN, Texas                    BOB INGLIS, South Carolina
LYNN WOOLSEY, California             GUS BILIRAKIS, Florida
SHEILA JACKSON LEE, Texas
BARBARA LEE, California
SHELLEY BERKLEY, Nevada
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
                   Richard J. Kessler, Staff Director
                Yleem Poblete, Republican Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

The Honorable Eric Goosby, United States Global AIDS Coordinator, 
  U.S. Department of State.......................................     8
Thomas R. Frieden, M.D., M.P.H., Director, Centers for Disease 
  Control and Prevention, and, Administrator, Agency for Toxic 
  Substances & Disease Registry..................................    19
Anthony S. Fauci, M.D., Director, National Institute of Allergy 
  and Infectious Diseases (NIAID), National Institutes of Health.    37
Ms. Paula Akugizibwe, Advocacy Coordinator, AIDS and Rights 
  Alliance for Southern Africa (ARASA)...........................    72
Wafaa El-Sadr, M.D., M.P.H., Director, International Center for 
  AIDS Care and Treatment Programs (ICAP), Mailman School of 
  Public Health, Columbia University.............................    84

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

The Honorable Howard L. Berman, a Representative in Congress from 
  the State of California, and Chairman, Committee on Foreign 
  Affairs: Prepared statement....................................     3
The Honorable Eric Goosby: Prepared statement....................    11
Thomas R. Frieden, M.D., M.P.H.: Prepared statement..............    21
Anthony S. Fauci, M.D.: Prepared statement.......................    39
Ms. Paula Akugizibwe: Prepared statement.........................    76
Wafaa El-Sadr, M.D., M.P.H.: Prepared statement..................    88
The Honorable Ileana Ros-Lehtinen, a Representative in Congress 
  from the State of Florida: Prepared statement..................    96

                                APPENDIX

Hearing notice...................................................   104
Hearing minutes..................................................   105
The Honorable Donald M. Payne, a Representative in Congress from 
  the State of New Jersey: Prepared statement....................   106
The Honorable Russ Carnahan, a Representative in Congress from 
  the State of Missouri: Prepared statement......................   108
The Honorable Sheila Jackson Lee, a Representative in Congress 
  from the State of Texas: Prepared statement....................   110
The Honorable Christopher H. Smith, a Representative in Congress 
  from the State of New Jersey: Material submitted for the record   117
Written responses from the Honorable Eric Goosby, Thomas R. 
  Frieden, M.D., M.P.H. and Anthony S. Fauci, M.D., to questions 
  submitted for the record by the Honorable Russ Carnahan........   132
Written responses from the Honorable Eric Goosby, Thomas R. 
  Frieden, M.D., M.P.H. and Anthony S. Fauci, M.D., to questions 
  submitted for the record by the Honorable Barbara Lee, a 
  Representative in Congress from the State of California........   135


 PEPFAR: FROM EMERGENCY TO SUSTAINABILITY AND ADVANCES AGAINST HIV/AIDS

                              ----------                              


                     WEDNESDAY, SEPTEMBER 29, 2010

                  House of Representatives,
                              Committee on Foreign Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:40 a.m., in 
room 2172, Rayburn House Office Building, Hon. Howard L. Berman 
(chairman of the committee) presiding.
    Chairman Berman. The hearing will come to order. We are 
going to be joined very soon by my friend from New Jersey Mr. 
Smith, and he is okay with us starting the hearing. In a moment 
I will recognize myself and then Mr. Smith for up to 7 minutes 
each for the purpose of making an opening statement.
    The chair and ranking member of the Africa and Global 
Health Subcommittee aren't here, and Mr. Payne probably won't 
be able to get here until 10 o'clock or so, so if the other 
members here want to make a 1-minute opening statement, you are 
welcome to do so. I know you are both very interested in this 
subject.
    The purpose of today's hearing is to review the progress 
PEPFAR has made toward reversing the global threat posed by the 
AIDS pandemic and how those efforts have set the stage to 
transform PEPFAR from an emergency initiative to a sustainable 
program.
    This morning, we are going to hear about some outstanding 
achievements and promising research that gives hope for 
increasing our ability to reverse the spread of the disease. We 
also will hear about the challenges we still face if we are to 
accomplish the ambitious goals set forth in the Tom Lantos and 
Henry J. Hyde United States Global Leadership Against HIV/AIDS, 
Tuberculosis and Malaria Reauthorization Act of 2008.
    This legislation, which built on the successes of the 
original legislation, the U.S. Leadership Against HIV/AIDS, 
Tuberculosis and Malaria Act of 2003, is a prime example of the 
bipartisan support that exists to fight the global HIV/AIDS 
pandemic. The fact that both sides joined together to bring 
positive change demonstrates that saving lives around the world 
is not a Republican or Democratic issue. It is a priority that 
all Americans share.
    PEPFAR faced many challenges during its first 5 years, 
including weak health care delivery systems, poor 
infrastructure, expensive and unavailable drugs, and limited 
workforce. These factors kept millions infected with the 
disease isolated from the care and treatment they needed.
    Social barriers like stigma, gender inequality, and 
prejudices against men-who-have-sex with men, commercial sex 
workers, and intravenous drug users, compounded the challenges 
to expanding services to those in need.
    But PEPFAR successfully invested in strengthening health 
care systems, training new health care personnel, purchasing 
affordable drugs, and helped to remove stigma and empower women 
and girls and other at-risk populations.
    In the face of controversy and our own economic challenges, 
Congress remained unified behind a single humanitarian purpose. 
Even in the face of our differences, we never lost sight of the 
goal to save the lives of millions of poor human beings who do 
not have the resources and means to save themselves and prevent 
the spread of AIDS.
    In preventing the spread of AIDS, we are not simply 
achieving the humanitarian objective of saving lives and 
preventing suffering. We also are advancing economic growth and 
building democratic stability by preserving the health of 
productive citizens, enabling people to support their families 
and contribute to the economic, social and political life of 
their communities.
    Last week the United Nations General Assembly convened a 
summit to discuss progress to date on achieving the Millennium 
Development Goals. Addressing the AIDS pandemic has had an 
impact across all of the MDGs. We must ensure that our 
commitment to fighting AIDS is designed to reinforce other 
critical health and developmental priorities.
    Today we have some good news in spite of the sobering 
impact the pandemic continues to have in poor countries. 
Globally, the overall rate of new HIV infections has slowed and 
prevalence rates have leveled off. According to the 2009 UNAIDS 
report, new HIV infections have been reduced by 17 percent over 
the past 8 years.
    In 2008, sub-Saharan Africa reported 14 percent fewer new 
infections than in 2001. In East Asia, new HIV infections 
declined by nearly 25 percent and in South and Southeast Asia 
they declined by 10 percent.
    Scientists from the U.S. and Africa are conducting research 
on the use of anti-retroviral drug treatment as part of 
prevention. Preliminary results demonstrated that ARVs could 
both keep a people well and prevent infections. For example, in 
Africa, a seven-country study was undertaken in which one 
partner was infected and the other was not. After 3 years, only 
one uninfected partner was HIV-positive when the infected 
partner was on an antiretroviral therapy. And in South Africa, 
researchers recently identified a new microbicide that may 
significantly reduce HIV infection rates in women.
    Based on these and other promising developments, it is fair 
to conclude that our ambitious investment in AIDS prevention, 
treatment and care programs has helped make an historical 
difference and there is sufficient epidemiological evidence to 
give us hope that this scourge on humankind can be defeated 
within our lifetime.
    While there is good news to report, we can't forget about 
the sheer magnitude of the epidemic. We still have 33.4 million 
people living with HIV worldwide and only 42 percent of those 
in need of treatment have access. Two-point-seven million 
people were newly infected in 2008, 14 million children in 
Africa have been orphaned by AIDS and around 430,000 children 
are born with HIV each year.
    U.S. global leadership has been extremely important in the 
fight against HIV/AIDS. President Obama, like President Bush 
before him, has made it clear the U.S. has a moral commitment 
to combat this deadly disease. We owe it to ourselves and our 
fellow Americans to ensure that we live up to these 
commitments, enshrined in law and policy. To that end, we must 
continue to strengthen our work with other bilateral donors, 
multilateral institutions, recipient countries, and local and 
international NGOs.
    [The prepared statement of Mr. Berman follows:]

    
    
    
    

    Chairman Berman. We have two very distinguished panels of 
witnesses here today to discuss these important issues. I look 
forward to hearing their testimony. Before I turn it over to 
Mr. Smith, who has done a tremendous amount on this issue, I do 
want to acknowledge and welcome the presence of a number of 
women members of Parliament from 12 African countries, 
including the Deputy Prime Minister of Zimbabwe, the Honorable 
Khupe. Thank you very much for being here, and we welcome you.
    Now I am pleased to yield to the gentleman from New Jersey 
for any remarks he may like to make.
    Mr. Smith. Thank you very much, Mr. Chairman, for holding 
this very important hearing on the President's Emergency Plan 
for AIDS Relief. I want to thank you and your predecessor Tom 
Lantos, and certainly Congressman Henry Hyde, both who chaired 
this committee, like you, who were very, very aggressive in 
promoting this program as well as the legislation.
    President George W. Bush described in his 2003 State of the 
Union Address how hospitals in rural South Africa were telling 
people, ``You have got AIDS, we can't help you, go home and 
die.'' President Bush committed the United States to assist 
African countries in overcoming the HIV/AIDS scourge not only 
with substantial resources, but also by achieving specific 
goals with measurable targets. And this effort was to be 
undertaken in countries that for the most part had poor health 
infrastructures, a sick and dying health care workforce, and 
other daunting obstacles. Many said it couldn't be done. PEPFAR 
proved them wrong.
    Working with the President, Congress passed the United 
States Leadership against HIV/AIDS, Tuberculosis and Malaria 
Act. Thanks to strong continued bipartisan support, PEPFAR can 
now boast about directly treating over 2.4 million people with 
lifesaving antiretroviral drugs. Nearly 340,000 babies born to 
HIV-positive mothers were born HIV free thanks to PEPFAR 
prevention of mother-to-child transmission programs. Almost 11 
million people affected by HIV/AIDS have received care, 
including 3.6 million orphans and vulnerable children. And in 
Fiscal Year 2009 alone, 29 million people were counseled and 
tested for HIV thanks to PEPFAR.
    Despite these successes I would like to highlight several 
concerns. One is the administration's implementation of PEPFAR 
as part of the new Global Health Initiative, of which PEPFAR is 
the major component, in the absence of authorizing legislation. 
I understand the administration intends through the Global 
Health Initiative to change the way the U.S. Government 
conducts its foreign assistance in this area at a fundamental 
level. I would strongly argue that such a change requires 
legislative authorization, given the amount of taxpayer money 
and important policies that are at stake.
    Another major concern is GHI's emphasis on integrating HIV/
AIDS programming with family planning as well as various health 
programs. This is being undertaken in the context of a family-
planning program, which, due to President Obama's rescission of 
the Mexico City policy, now includes foreign nongovernmental 
organizations that provide, support and seek the expansion of 
access to abortion. When one considers that this involves over 
$715 million in family-planning funding under the Fiscal Year 
2011 proposed budget, the ability for abortion groups to 
leverage this funding in relation to U.S. HIV/AIDS funding 
under the GHI is deeply disturbing.
    Furthermore, it now appears that the considerable sums that 
the United States contributes to the Global Fund to Fight AIDS, 
TB and Malaria--$1 billion in Fiscal Year 2010--may contribute 
to a new Global Fund initiative to fund abortions. This 
possible intervention, part of the Global Fund's effort to 
contribute to the Millennium Development Goals, is described in 
a document presented to the Global Fund Board at its meeting in 
April of this year. This paper is intended to facilitate the 
Board's discussion of the Fund's role as a, 
quote, deg. ``strategic investor in maternal and child 
health.'' It asserts that the Global Fund will optimize--this 
is a quote--``existing interventions to improve the health 
outcomes for women and children'' by identifying areas for 
greater integration of HIV, TB and malaria services with 
``sexual and reproductive health services.'' In the chart 
identifying ``interventions that could be supported with the 
new funding,'' the paper explicitly proposes abortion.
    Abortion, I would say to my colleagues and to our 
distinguished panelists, is by definition infant mortality, and 
it undermines the achievement of the fourth millennium goal. 
There is nothing, nothing benign or compassionate about 
procedures that dismember, poison, induce premature labor or 
starve to death a child. Indeed the misleading term ``safe 
abortion'' misses the point that abortion, all abortion, legal 
or illegal, is unsafe for the child, and all is fraught with 
negative health consequences, including emotional and 
psychological damage, for the mother.
    Monies that the U.S. contributes to the Global Fund are 
ultimately taxpayer dollars, and polls show that 61 percent of 
U.S. taxpayers do not want government funding paying for 
abortions. Our U.S. delegation should keep this in mind as it 
takes up this question with the rest of the Board at the next 
meeting in December.
    And finally, one final concern is the importance of not 
only including but also reaching out to faith-based 
organizations in all of our global health programming. Given 
studies that show up to 70 percent of health care in Africa--
and that is a WHO number--is provided by faith-based hospitals, 
clinics and organizations, it is imperative for the continued 
success of PEPFAR to have them as a primary partner. Thus I 
would hope that the administration is assisting local 
governments in developing strategies that include faith-based 
networks as an integral part of their health system. Their 
effort also necessitates respect for the conscience clause 
provisions contained in the Leadership Act and reaffirmed and 
strengthened by this committee and by this House and the Senate 
in the 2008 reauthorization.
    Mr. Chairman, I look forward to our distinguished 
panelists' comments, and I thank you for yielding.
    The gentleman has yielded back his remaining time, and for 
1-minute opening statements any members of the committee?
    Ambassador Watson, are you----
    Ms. Watson. I was going to defer to Barbara Lee.
    Chairman Berman. The gentlelady from California has 
deferred to the gentlelady from California.
    Ms. Lee. Thank you again, Congresswoman Watson.
    Thank you again, Chairman Berman, for this hearing. Thank 
all of you for being here and specifically for the work that 
you do each and every day to save lives.
    I, of course, as you know, helped write the initial PEPFAR 
with Chairman Hyde, and we sorted through many of these issues 
that have been raised by Congressman Smith, and believe you me, 
I believed then as I believe now the countries should be able 
to determine their own plan. However, we didn't win that one, 
and we know for a fact that PEPFAR funds are not used for 
abortions. I have been out many times, as have members of this 
committee, so I thought we had settled that, not to my 
satisfaction, but I thought we had settled it.
    Secondly, let me just say I did participate recently at the 
International AIDS Conference in Vienna, and I know there is a 
lot of concern about the extent of our commitment to fighting 
this disease. The global economic crisis has seemed to have 
dried up in many quarters, the political will and the 
resources. Yet here in our own country we know that the drive 
for military spending to build new and even more deadly weapons 
systems, this debate continues to go unabated.
    And so I think we need to really focus on how we can move 
forward with PEPFAR, with the International AIDS Conference 
coming to Washington, D.C., in 2012. I hope we can show the 
world that the United States is seriously committed to fighting 
this pandemic, and to setting our goal of an AIDS-free 
generation, and to use PEPFAR as an example for our own 
domestic strategy here in America.
    Thank you again, Mr. Chairman.
    Chairman Berman. Thank you. And just before that I do want 
to--Ms. Lee's opening comments reminded me that in the very 
beginning of all this back in 2001, 2002, she was a driving 
force to the initial legislation.
    Ambassador Watson.
    Ms. Watson. Yes. Good morning, Mr. Chairman, and I want to 
thank you for holding this timely hearing on PEPFAR and the 
advances against HIV/AIDS. I concur with the two of you, Ms. 
Lee and the chair.
    Currently 33.4 million people are living with HIV and AIDS 
worldwide, with 2.7 million new infections in the year 2008. 
Through President Bush's PEPFAR initiative, it has made great 
strides in responding to the emergency of the global pandemic, 
and we must now look to create a substantial approach to 
confronting HIV/AIDS.
    President Obama's 5-year strategy aims to achieve just 
that. Unfortunately, it is unclear how we will transition to a 
country-owned, sustainable health system in struggling nations 
that will be able to respond to the plethora of diseases that 
plague the developing world. I look forward to hearing from the 
administration about how this transition will take place.
    So I want to yield back and thank you, Mr. Chairman.
    Chairman Berman. The time of the gentlelady is expired.
    Anyone else seek recognition for an opening statement? The 
gentlelady from California.
    Ms. Woolsey. What would you do without us, Mr. Chairman?
    Chairman Berman. I wouldn't be here.
    Mr. Woolsey. The women from California. That is true.
    Thank you all for being here, and I am looking forward to 
your testimony.
    I have to apologize. We will be in and out because of other 
things. But I am really interested in hearing how you are 
integrating HIV/AIDS treatment and prevention with a larger 
role of women's health and maternal health. I think that 
pulling all of this together into one conversation is very, 
very important. Are we getting more bang for our buck with 
PEPFAR by doing this? And are women getting health care in a 
one-stop shop style?
    So I am just looking forward to hearing all of that from 
you, and I thank you for all you know and all you do for 
PEPFAR. Thank you very much.
    Chairman Berman. The time of the gentlelady has expired. 
Any other members seeking recognition for an opening statement? 
If not, it is my pleasure now to introduce our first panel.
    It is an amazing logistical feat that the three of you 
could actually get together in terms of your calendars and ours 
to be here, and we are very grateful that you are.
    Ambassador Eric Goosby serves as United States Global AIDS 
Coordinator. In this capacity Ambassador Goosby oversees 
implementation of the U.S. President's Emergency Plan for AIDS 
Relief--that is the PEPFAR program--and leads all U.S. 
Government international HIV/AIDS efforts, including engagement 
with the Global Fund to fight AIDS, tuberculosis and malaria. 
Ambassador Goosby has over 25 years of experience developing 
health care delivery systems, served as the first director of 
the Ryan White Care Act at the U.S. Department of Health and 
Human Services, and I believe has a California connection.
    Dr. Thomas Frieden became director of the Centers for 
Disease Control and Prevention and administrator of the Agency 
for Toxic Substances and Disease Registry in June 2009. From 
2002 to 2009, he served as a commissioner of the New York City 
Health Department, one of the world's largest public health 
agencies. Dr. Frieden previously worked for CDC from 1990 to 
2002, where he began his career as an epidemiologic 
intelligence service officer.
    Dr. Anthony Fauci was appointed director of the National 
Institute for Allergy and Infectious Diseases in 1984. He 
oversees an extensive research portfolio of basic and applied 
research to prevent, diagnose and treat infectious diseases 
such as HIV/AIDS and other sexually transmitted infections, 
influenza, tuberculosis, malaria, and potential agents of 
bioterrorism. Dr. Fauci is the recipient of numerous 
prestigious awards for his scientific accomplishments, 
including the Presidential Medal of Freedom and the National 
Medal of Science.
    Gentlemen, we are honored to have you here.
    Ambassador Goosby, why don't you start? All of your 
prepared statement will be included in the record, and we will 
be grateful for you summarizing your main points.

 STATEMENT OF THE HONORABLE ERIC GOOSBY, UNITED STATES GLOBAL 
           AIDS COORDINATOR, U.S. DEPARTMENT OF STATE

    Ambassador Goosby. Thank you very much, Chairman Berman, 
Ranking Member Ros-Lehtinen and members of the committee. Thank 
you for this opportunity to discuss the progress we have made 
under PEPFAR with your long-standing bipartisan support.
    I am pleased to be here with my friends and colleagues Dr. 
Tom Frieden and Dr. Tony Fauci. All of the agencies involved in 
PEPFAR contribute their strengths to a unified interagency 
effort that has maximized our impact.
    I serve with Dr. Frieden and Dr. Shah of USAID as the 
operations committee for President Obama's Global Health 
Initiative. GHI builds on our shared interagency experience, 
and I appreciate the committee allowing us to speak to it and 
the commitment on all agencies' parts to collaboration.
    I have been working on HIV/AIDS for almost 30 years. Five 
to six years ago those of us who engaged in HIV work in Africa 
saw daily tragedies on a vast scale. Yet today with American 
leadership, PEPFAR has brought about a dramatic transformation.
    I have outlined the results to date in my written 
testimony. With PEPFAR as its cornerstone, GHI will support 
coordinated interventions to increase our ability to save lives 
from AIDS and other challenges. With the support of this 
Congress and the Obama administration, the number of people 
receiving HIV prevention, treatment and care will continue to 
grow. In addition to doubling the number of babies born HIV-
free, the United States will support the prevention of more 
than 12 million new HIV infections, HIV treatment for more than 
4 million, and care for more than 12 million, including 5 
million orphans and vulnerable children.
    Our prevention, care and treatment programs are integrally 
linked. We have led the world in rapidly scaling up biomedical 
prevention, such as male circumcision and prevention of mother-
to-child transmission.
    PEPFAR has also worked to reduce treatment costs and to 
expand service delivery. Reflecting a key GHI principle, we 
support operations research to identify innovations and best 
practices to save more lives.
    Simply put, our work has been and continues to be about 
saving lives as part of our shared global responsibility to 
make smart investments. Partnerships are an overarching 
principle for the Global Health Initiative. The United States 
provides nearly 60 percent of donor government funding for HIV/
AIDS, a leadership role we are proud of and which, thanks to 
Congress' reauthorization of PEPFAR, will continue.
    Yet the global need is a global responsibility and all have 
roles to play. An important mechanism for this is the Global 
Fund. The United States has been its largest donor, providing 
more than $5.1 billion, and providing support for grant 
implementation at the country level that has proven crucial to 
ensuring the grants can deliver.
    As we implement PEPFAR's 5-year strategy, let me highlight 
three priorities that reflect the GHI principles. First, saving 
more lives through PEPFAR activates our ability to focus on and 
be part of the Global Health Initiative. During its first phase 
PEPFAR focused on meeting ambitious goals for delivery of 
prevention, care and treatment. Moving forward, make no 
mistake, we will support expansion of these core services.
    Yet people affected by HIV are not defined by the virus 
alone. Like everyone else, they have a change and range of 
other health needs. That is why integration is a core GHI 
principle, and GHI will help to holistically address these 
needs. At the same time we also want to reach the clients of 
other programs, such as maternal and child health, with HIV 
interventions. For example, women who come to antenatal clinics 
are an ideal population for PMTCT programs. Integration under 
GHI offers the real opportunity of increasing our impact on 
health and, again, saving more lives.
    A second priority is addressing gender issues with HIV 
programming. GHI recognizes that focusing on women, girls and 
gender equity is a force multiplier benefiting women, their 
families and the communities. AIDS is the leading cause of 
death of women of reproductive age worldwide, and in Africa 
nearly 60 percent of those living with HIV are women. During 
its first phase PEPFAR began a five-point gender strategy 
seeding countries with small initiatives. We are now expanding 
them with a focus on PMTCT and country-led projects.
    One risk factor for HIV is the tragedy of gender-based 
violence. We are investing $30 million to combat it in three 
severely burdened countries, and in all countries we are 
supporting post-rape care, while also seeking to prevent sexual 
violence in the first place. Last week at the Clinton Global 
Initiative, we joined the Together for Girls public-private 
partnership to combat violence against girls.
    Lastly, we are focused on the GHI principle of expanding 
country ownership and local capacity to build a sustainable 
program. As we responded to the HIV emergency in the first 
phase of PEPFAR, we worked largely through international 
partners. A major priority we have now added is increasing the 
capacity of countries to manage, oversee and operate their 
health-delivery systems.
    Moving forward we will increasingly emphasize a third 
dimension, community empowerment. As we pursue support for 
health systems under GHI, we know local communities can ensure 
accountability in a way that outsiders never can. That feedback 
dialogue is essential for true sustainability.
    In conclusion, we are making great strides, but much work 
remains. We must keep our eyes on the prize, and that is to 
save more lives. I remain grateful for your ongoing support for 
this effort and look forward to the questioning.
    [The prepared statement of Ambassador Goosby follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Chairman Berman. Dr. Frieden.

STATEMENT OF THOMAS R. FRIEDEN, M.D., M.P.H., DIRECTOR, CENTERS 
FOR DISEASE CONTROL AND PREVENTION, AND, ADMINISTRATOR, AGENCY 
            FOR TOXIC SUBSTANCES & DISEASE REGISTRY

    Dr. Frieden. Thank you very much. Good morning, Chairman 
Berman and Ranking Member Smith. It is a pleasure and an honor 
to be here along with my friends and colleagues, Dr. Goosby and 
Dr. Fauci.
    Over the past year I have had the great privilege of 
visiting PEPFAR services in Ethiopia, Tanzania, Mozambique, 
Nigeria and other countries. I have been inspired by the proof 
that there is a critical impact of the leadership and support 
of this committee of the wonderful work of our staff and our 
partners on the ground and of the effectiveness of the PEPFAR 
model as a true whole-of-government approach.
    The CDC deeply appreciates the leadership provided by OGAC 
and the important work of NIH, as well as USAID and other 
implementing partners.
    CDC has a unique role and history in global health. It is 
essentially in CDC's DNA, going back to the 1960s and 1970s 
when, with WHO, CDC led the global smallpox eradication 
program. Among other initiatives today we detect and stop 
outbreaks, support epidemiologic and laboratory systems, help 
prevent and control malaria, support progress in the control of 
measles and the eradication of polio.
    We also fundamentally improved the capacity of partner 
governments to plan, implement and monitor their own programs. 
We have a unique role supporting international organizations, 
providing consultations, training and embedded staff.
    Today more than 2.5 million people are alive, productive 
and healthy who would otherwise have been dead or dying without 
PEPFAR. Last year 100,000 babies who would otherwise have been 
infected were born HIV free because of PEPFAR.
    The first slide shows the dramatic expansion in the 
proportion of met need for treatment in countries, the original 
PEPFAR countries, in the southern cone of Africa. The second 
slide shows the dramatic scale-up in treatment in recent years.
    In short, not only are communities and systems throughout 
the world dealing with HIV better, but they are better prepared 
to deal with other health problems. PEPFAR, with OGAC's whole-
of-government leadership, is working.
    We face two key challenges going forward. First we need to 
scale up treatment sustainably and cost-effectively to reach 
even more people; and second, we need to take prevention to the 
next level.
    When Congress had the wisdom to authorize PEPFAR and OGAC's 
whole-of-government model, CDC was well poised to contribute 
because of our work globally and in this country, and their 
involvement in HIV since the first days of the epidemic. We 
were already on the ground in sub-Saharan Africa, monitoring 
and directing efforts to understand the nature of the epidemic, 
and developing and disseminating the latest science, an 
effective tool to control HIV.
    CDC and HHS is the counterpart of ministries of health, and 
we work in a peer-to-peer relationship. To implement programs 
effectively and sustainably, it is essential that they be 
inextricably linked with rigorous evaluation, capacity 
development, systematic laboratory and capacity tracking, and 
practical research. We have unique expertise evaluating whether 
investments are working, and doing cutting-edge research to 
drive improved service delivery, and to make more effective use 
of scarce resources.
    The committee has recognized that sustainable systems and 
country ownership are essential components in PEPFAR, and that 
is our commitment at CDC as well. To further scale up 
effectively, PEPFAR is transitioning to more local, sustainable 
and cost-effective programs. Already nearly half of CDC's 
funding is implemented thorough cooperative agreements with 
health ministries or other local in-country partners, 
including, very importantly, faith-based organizations resident 
in their country, which are very important service delivery 
partners for us.
    Treatment costs continue to decrease as we decentralize 
care. And the next slide shows that steady decrease in unit 
costs as we transition management to local partners, streamline 
monitoring, realize cost savings through generics, and ensure 
treatment at the most high-prevalent sites for pregnant women 
and TB/HIV coinfected people.
    Prevention is critical. We can drive incidence down with a 
comprehensive package of interventions as shown on the next 
slide, including a series of proven and some potential but 
high--potentially high-impact interventions. Prevention of 
maternal-to-child transmission, HIV screening link to care and 
treatment, safe blood, male circumcisions, condoms and other 
proven interventions can make a big difference not only 
individually, but, as the next slide shows, in combination. We 
anticipate that there can be synergistic decreases in 
incidence.
    As we think of multicomponent prevention, we make the 
analogy to multidrug treatment for HIV. The breakthrough in HIV 
treatment came when we were able to use multiple drugs to stop 
replication of the virus in multiple pathways. In the same way 
we hope to have multiple ways of stopping transmission in a 
community to drive incidence down.
    PEPFAR is a critical platform to build the Global Health 
Initiative, and the whole-of-government process overseen by 
Ambassador Goosby is a model of effective collaboration. This 
gains efficiencies by using existing infrastructure of various 
agencies and funding programs based on comparative advantage.
    PEPFAR embodies the principles of GHI to achieve specific 
health outcomes, strengthen systems for sustainable 
improvements, maximize impact of all dollars, encourage country 
ownership, improve monitoring and evaluation, and accelerate 
research and innovation.
    In conclusion, PEPFAR is a tremendous success. The 
confidence this committee has had in us all is paying off in 
lives saved, infections prevented and systems strengthening. 
The interagency, OGAC-led model that Congress has been so 
supportive of is working. We are proud of the important role 
CDC is having in this success and will amplify PEPFAR's success 
as we move forward with GHI by implementing programs which 
reach more people and stretch our dollars even further.
    We are optimistic about the future, about the ability to 
reach more people, drive down incidence, reduce costs, and 
build sustainable capacity.
    Thanks you very much for the opportunity to be here today, 
and I look forward to answering your questions.
    Chairman Berman. Thank you.
    [The prepared statement of Dr. Frieden follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Chairman Berman. Dr. Fauci.

    STATEMENT OF ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL 
INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES (NIAID), NATIONAL 
                      INSTITUTES OF HEALTH

    Dr. Fauci. Mr. Chairman, thank you for calling this 
hearing. Mr. Smith, thank you, and members of the committee. It 
is really a great pleasure for me to be able to testify before 
you today together with my close friends and colleagues Dr. 
Frieden and Dr. Goosby.
    What I would like to present to you over the next few 
minutes is the role of the NIH basic and clinical research 
endeavor in partnership to help the PEPFAR program implement 
its fundamental mission.
    As shown in this first slide, the advances in HIV research 
over the last 29 years have been really nothing short of 
breathtaking from the very beginning of the determination of 
the etiology, to the pathogenesis, rapid diagnosis, prevention 
modalities, treatment, and now the promising advances made in 
the arena of an AIDS vaccine.
    On the next slide you see the four areas that I would like 
to address very briefly with regard to the importance of these 
findings to the mission of PEPFAR--importantly treatments, 
obviously prevention, but also a word or two on capacity 
building and implementation science.
    On the third slide is a list of the 30 FDA-approved 
antiretroviral drugs that have been successfully used in 
combination to literally transform the lives of HIV-infected 
individuals. From the very beginning, in the mid-1980s, after 
we identified the etiologic agents, we began the basic and 
clinical research to develop these drugs, to prove their 
effectiveness in clinical trials, and to ultimately determine 
the optimal way to use them. This has been a great success.
    On the next slide you see some interesting figures. I began 
taking care of HIV-infected individuals in the summer of 1981, 
within 2 months after the first cases were identified by the 
CDC. I have been doing that ever since, up to the present time. 
When a person would walk into my clinic in the summer of 1981, 
usually with advanced disease, the person had a life expectancy 
of approximately 26 weeks. If a 20-year-old comes into my 
clinic tomorrow with newly acquired HIV infection, and I start 
him on this drug, I can confidently tell him that if he adheres 
to the regimen, we mathematically predict that that person will 
live an additional 50 years until they are at least 70 years 
old.
    PEPFAR is now beginning to translate those findings to the 
developing world, the countries in which they have a major 
impact. We are not exactly at those life-expectancy numbers 
yet, but were it not for PEPFAR, we would still be in the 
situation that I was in in the summer of 1981 with essentially 
nothing to do for these patients.
    If you go to the next slide, these are the proven 
prevention modalities for HIV. Many of these have been proven 
by the work of the NIH and the work of the CDC and other 
agencies. I want to point out three of them that have 
particular applicability to PEPFAR.
    The first is the prevention of mother-to-child 
transmission, the use of antiretroviral drugs to block the 
transmission from mother to child, something that is being 
implemented with great lifesaving effect by PEPFAR. Another is 
adult male circumcision, which NIH-funded studies proved beyond 
a doubt is an important way to prevent the acquisition of HIV 
infection. And the other is proving that the proper use of 
condoms can block the transmission of HIV. The issue is that we 
need to implement these, because only 20 percent of people who 
benefit from these preventive modalities actually have access 
to them. What PEPFAR is doing is bridging that gap.
    If could I have the next slide. You mention treatment as 
prevention. This is really, in my opinion as an AIDS researcher 
and public health official, an important wave of the future. 
Some examples of success already are shown on this slide.
    A very exciting study that took place in southern Africa, 
called the CAPRISA study, used 1 percent tenofovir, an 
antiviral, in a gel, to block the transmission of HIV to women 
who used this microbicide. We need to improve on this, and we 
will. And this is something that PEPFAR is very interested in 
implementing.
    It was shown in a study in Africa that discordant couples, 
one of whom was infected and the other one was not, if you 
treated the infected person, you had a 92 percent decrease in 
the transmission to the uninfected partner.
    And then you mentioned the issue of test and treat, which 
Dr. Frieden was mentioning. If you could penetrate the 
community and get as many people as possible on therapy, it 
looks now from mathematical models and as evidenced in places 
like Vancouver and San Francisco that you could actually, by 
decreasing the community viral load, prevent HIV transmission 
to a certain degree.
    And then finally there is the development of a vaccine. We 
are not there yet, but the results over the past few years have 
been very encouraging.
    I want to close by mentioning two additional issues. One is 
capacity-building, and that is to develop in-country leadership 
and strengthen the clinical and research capacity. The 
President mentioned this in his recent speech to the U.N., and 
Ambassador Goosby has stressed this from the very beginning. We 
want these countries and their people to be able to have the 
capacity to continue to do these things on their own. An 
example of this is the Medical Education Partnership Initiative 
with HRSA, which builds clinical-care capacity in sub-Saharan 
Africa.
    In addition, on this last slide is implementation science. 
What we mean by that is how can we best translate the research 
findings that now work in the developed world to the in-the-
trenches, on-the-ground situation that Dr. Goosby and his 
colleagues have to deal with in places like sub-Saharan Africa 
and the Caribbean, and we are in strong partnership with PEPFAR 
in this regard.
    On the final slide I want to emphasize the common goal that 
all of us have. The NIH, the CDC, HHS, PEPFAR, USAID, all of us 
have the common goal of controlling and ultimately ending the 
HIV pandemic. PEPFAR is completely integral and essential to 
the accomplishment of that goal. So I strongly urge you to 
continue your strong support for the truly lifesaving program 
that is PEPFAR. Thank you.
    [The prepared statement of Dr. Fauci follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Chairman Berman. Thank you, and thank all of you. And I now 
yield myself 5 minutes to begin the questioning.
    Now, Ambassador Goosby, you touched on it, but develop this 
a little more fully. We are trying to move from emergency to 
sustainability. The issue of financing, of course, is quite 
critical. The majority of countries receiving either PEPFAR or 
Global Fund resources don't have the budget to take on the full 
funding of these programs, yet these programs have to be 
integrated within their national health care system.
    Could you sort of spell out PEPFAR's strategy to integrate 
AIDS programs into their systems and without overwhelming their 
budgets?
    Ambassador Goosby. Well, thank you, Mr. Chairman.
    You are correct to highlight that as a critical need in all 
of our program, thinking both in the past and in the future. 
Our ability to move from an emergency response to a sustained 
response is integrally related, and our ability to make sure 
that the programs that we have put up and established in the 
emergency phase do not lose their impact or their ability to 
expand to the changing needs of the population that use them.
    Our feeling is that country ownership is critical. By 
country ownership we are focused really on both the government 
as the public sector component, but also just as importantly on 
the community and the civil society around it. All three are 
required for the appropriate establishment of a continuum of 
care and services, a continuum of prevention interventions that 
impact the community in the region and areas that they are most 
vulnerable. So understanding the epidemic in the context of 
each country's epidemic is the critical piece.
    Our commitment to working with countries to continue to 
support programming includes both a financial commitment as 
well as the realization that capacity expansion within the 
ministries of health, the ministries' ability to play a 
technical assistance role for provincial ministries of health, 
are all part of the vision that we carry and try to align in 
each of the countries that we are in.
    Chairman Berman. Thank you.
    Dr. Frieden, you made reference in your testimony, you 
talked about your trips, and in your prepared testimony you 
made reference to CDC's relationship with the African Center 
for Integrated Laboratory Training.
    Who has been trained? And does the laboratory training 
prepare technical personnel to work with diseases other than 
AIDS, TB and malaria?
    Dr. Frieden. Thank you very much for the question, Mr. 
Chairman. The African Center trains people not just from the 
country where it is resident, but throughout the region. We 
have been able to promote laboratory network strengthening, 
including the beginnings of an accreditation system, so that 
when you get a result back from a laboratory, you can be 
confident in its accuracy. We have trained not only the 
laboratorians, but the people who supervise and manage the 
laboratory systems to establish sustainable laboratory services 
not just in HIV, but also more broadly to strengthen the health 
systems, whether that is TB testing or basic laboratory 
testing.
    I have been quite impressed by the systems that I have seen 
out there. They are very reliable. They include very complex 
testing, including CD4 counts and early infant diagnosis using 
the latest technologies, but also applied effectively within 
PEPFAR and to strengthen the system.
    So we see laboratory strengthening as one of the core 
pillars of strengthening a health system, and we have been 
delighted to be able to that with support from PEPFAR.
    Chairman Berman. The question--if I had time to ask and 
hear the answer to--I would be asking now to Dr. Fauci, is your 
remarkable testimony about some of the advances and connections 
between treatment and prevention. Unless you can say sort of in 
three words, but the question would be to what extent should 
that alter the way Congress approaches the funding of PEPFAR, 
or do you have the discretion within the program to make the 
adjustments that these conclusions might cause you to make 
without any particular changes in the way we are approaching 
the appropriations process? That is the question. We don't have 
time for the answer.
    Mr. Smith. I ask unanimous consent the gentleman have 2 
additional minutes.
    Chairman Berman. Could we make it at least 1 additional 
minute with unanimous consent, because I think it is----
    Dr. Fauci. Well, to answer it in as broad an applicable way 
as possible is this just underscores in my mind how important 
what PEPFAR doing is. I mean, people often say we put a lot of 
money in something; is it really worth it? Well, the fact is 
that if you are trying to prevent infection and treat people 
who are infected, you actually get two for the price of one, 
because what we are starting to see is the support for 
treatment isn't at odds or in competition with prevention, it 
is actually part of prevention. So when you hear people from 
PEPFAR say that, when you hear Tom Frieden and his colleagues 
from the CDC say that, it really is true.
    I mean, all the data that is starting to accumulate now 
means that, in fact, you can, by treating people appropriately, 
ultimately prevent infection. So we have got to put aside the 
tension between treatment and prevention. They synergize with 
each other.
    Chairman Berman. Thank you.
    And now I am pleased to yield 5 minutes to the gentleman 
from New Jersey Mr. Smith.
    Mr. Smith. Thank you, Mr. Chairman.
    First of all, let me thank you for the most recent addition 
of enrollees for Uganda. I had been very critical--I am not the 
only one--that there was a straight-lining, and some additional 
36,000 people in Uganda will now get ARVs courtesy of the 
United States Government. So thank you for doing that, 
especially in light of the double duty that treatment is 
prevention, and I think that is very, very encouraging.
    Dr. Frieden, if you could maybe touch on briefly the issue 
of safe blood. I actually held a hearing several years ago when 
I chaired the Africa Subcommittee, and one of the issues we 
learned from WHO is maternal mortality can be reduced by 44 
percent, according to the witness from WHO, if safe blood were 
available. I know you have 14 initiatives going. In your 
testimony you speak to it. Maybe you might want to touch on 
that.
    And secondly, according to the WHO, and I said this in my 
opening statement, an overwhelming amount of health care is 
provided by faith-based entities--under the auspices of faith-
based communities in Africa. Forty percent of that is delivered 
by the Catholic community, and worldwide the Catholic community 
provides 25 percent of all care and prevention for HIV/AIDS 
patients.
    I would argue that failure to aggressively include faith-
based organizations in the Global Health Initiative will 
seriously undermine the efficacy and sustainability of our 
struggle to mitigate and hopefully end this pandemic that has 
so ravaged Africa and other parts of the world.
    I understand that the country ownership issue is central to 
the Global Health Initiative. Yet given the poor track record 
of the Global Fund, to which U.S. taxpayers donate over $5 
billion and counting, in its national ownership scheme known as 
the Country Coordinating Mechanisms, could you tell us what the 
administration is doing to ensure that faith-based 
organizations are not discriminated against in the allocation 
of grants at the country level? How does that figure into our 
partnership framework agreements? Are we saying this is 
something we think is important? Why create a new 
infrastructure when there is a preexisting one where rollouts 
can occur? And how do you plan to ensure that PEPFAR's 
conscience clause, which I offered to the original law--and it 
was actually strengthened when we went through the 
reauthorization. And Chairman Berman, the Democrats and 
Republicans were of one accord in strengthening that conscience 
clause--so that when it gets to that country level, the 
conscience clause is not shredded, and these faith-based 
organizations are not shown the door, and they are part of 
delivery of services?
    Dr. Frieden. Thank you very much. I will start, and then 
perhaps Ambassador Goosby will address it as well.
    The safe blood program really is a success story. It is now 
scaled up to all 60 countries with technical assistance, and it 
has been done in a way that builds local capacity. It has not 
been an external system imposed, but a system of helping 
countries establish, monitor and maintain a safe blood system, 
and that is critically important and a real win in HIV 
prevention and in confidence in the health care system.
    So I think it is a great example. It is an example of 
prevention. It is working, and, very importantly, it is working 
by building systems. I met with the staff who had helped to 
grow that. They were essential in improving that quality.
    And as we transition through the Global Health Initiative, 
we will be looking also at the appropriate use of blood and 
increasing to make sure that it is not being used when it is 
unnecessary, and is being used adequately, such as in the 
reduction of infant mortality where hemorrhage is a leading 
cause of death. And addressing emergency hemorrhage is 
something that we hope to be able to do in the Global Health 
Initiative as we transition from prevention of mother-to-child 
transmission to a broader sense of protecting mothers' lives.
    In terms of faith-based organizations, I agree completely. 
In many countries in which we work, there are superb service 
delivery platforms. They provide services where there are no 
other service providers. They provide them with very high 
quality and at very low cost, and we see them as essential 
partners, and we continue to work with them. In fact, as I 
mention in my oral statement, as we transition to local 
partners increasingly, and we are already--45 percent of our 
grants are local partners rather than U.S.-based--but as we 
continue and expand that transition, faith-based organizations 
have a very essential role to play.
    Mr. Smith. Real quick.
    Chairman Berman. We can give you unanimous consent for 1 
additional minute for the full answer to this.
    Mr. Smith. I mentioned the Global Fund because I have met 
with the Global Fund many times and their leadership about the 
exclusion of faith-based organizations, especially at the 
country coordinating mechanism level.
    In many of these countries, as we know, for years the 
churches collectively have been the bulwark in protecting human 
rights, and very often they are seen as the thorn in the side 
of governments, particularly as they matriculate from 
dictatorship to a democracy. So there is a reason to keep them 
at bay and look for other partners. And again, who hurts? It 
would be the potential patients.
    Ambassador Goosby. Well, let me just echo Dr. Frieden's 
statements around the faith-based organizations. They have 
historically played, as you have really eloquently outlined, a 
critical role in the delivery of health care in sub-Saharan 
Africa in particular. As you move from urban to rural, their 
importance increases, and in many countries where PEPFAR is 
working, the faith-based organizations really comprise the 
district hospital-level capability in many of the rural areas 
that we are in.
    That role is not going to change. Indeed, in many countries 
the faith-based organizations are part of the public health 
system. When a graph is charted of their referral, tertiary, 
secondary and district-level hospitals, the faith-based 
organization is often playing that role solely, as I said. They 
also have a series of clinics that reach out from that hospital 
base that again extend their reach and have been extensively 
engaged with in all of our programs in PEPFAR with completing 
continuums of care in services in both treatment and prevention 
fronts.
    So we are committed to continuing that and would look, if 
you had examples of concern or issues where it has come to your 
attention that someone has been excluded, we would be very 
interested in engaging with that directly.
    I would finally answer your Global Fund question to say 
that the CCM process, the country coordinating committees, are 
locally determined as to who sits on those seats. We do give a 
significant amount of resources to it. We see the Global Fund 
and PEPFAR as joined at the hip; our success is interdependent. 
Our planning together and defining unmet need and allocating 
resources is now getting much more sophisticated so the 
duplication overlap, the ability to take advantage of common 
procurement distribution systems, administrative oversight 
management, et cetera, it is all moving forward.
    We believe----
    Chairman Berman. Ambassador, the time has more than 
expired. So perhaps there is a way to get back to that.
    The gentlelady from California Ms. Lee is recognized.
    Ms. Lee. Thank you very much. And, yes, Mr. Chairman, we 
will get back to that.
    And let me just say I am glad you mentioned that Dr. Goosby 
has a California connection, but I am very proud to say he is 
my constituent----
    Ambassador Goosby. Absolutely.
    Ms. Lee [continuing]. And has done a very fine job in this 
position also, as he has in previous positions.
    With regard to the Global Fund, following the International 
AIDS Conference, of course, I sent a letter to the President 
along with 100 Members of Congress asking for $6 billion over 3 
years to fight--well, committed to the Global Fund. Together 
with PEPFAR our contributions have been responsible for 
treatment of 5 million people worldwide. So next week in New 
York, of course, the Global Fund is holding its replenishment 
hearing, and I wanted to find out where the administration 
stands on this request for a $6 billion pledge. Can we reach 
that target? If so, great; if not, why not?
    I think it is very important, because we want this 
announcement to be clear so that we can begin to leverage 
contributions from other donors who are still considering their 
pledge. So that is one question, Dr. Goosby.
    And then my second question any member of the panel could 
answer as it relates to the joint United Nations program on 
HIV/AIDS. I have been asked to serve as a Commissioner on the 
Global Commission on HIV and the Law. This new international 
Commission, the objective is to develop actionable, evidence-
informed, and human-rights-based recommendations supporting 
national legal environments that enable effective HIV responses 
and realize the human rights of those living and affected by 
HIV. The Commission will hold three meetings over the course of 
18 months. The first meeting, of course, is next week in 
Brazil.
    So I wanted to find out if you are aware of the Commission 
and its goal? Is the United States providing any direct 
support, whether technical or material, of the Commission? And 
can we count on your input, because I would like to talk to you 
about our input in terms of helping to overcome some of these 
legal barriers to providing access to services and to 
encouraging the research that is really necessary to fight this 
disease.
    Ambassador Goosby. Well, thank you, Congresswoman Lee, and 
you are my Congresswoman. Thank you.
    I think that the relationship between PEPFAR and the Global 
Fund has evolved. Our presence as a Board member on the Global 
Fund and our engagement with both the Executive Director and 
the Secretariat has given us an increasing opportunity to again 
lay this trackwork to merge our resources in a way that is 
highly efficient and increases both of our programs' impact at 
the country level. We are excited about that merging. We 
believe this will bring many more people into our care and 
treatment and prevention services and will save many more 
lives.
    Our ability to have a meaningful relationship with the 
Global Fund has been one of iterative dialogue around 
strengthening mechanisms for both the Secretariat as well as 
the CCM process.
    As the PEPFAR programs have staff in country, we are 
intimately aware in 80 countries in which we overlap with 
Global Fund of a lot of the implementation issues that come to 
bear, such as we saw in Uganda where our programs are connected 
to theirs. If Global Fund programs are performing well, we move 
together. If either of us fall in that ability to move patients 
through, to identify clients, to address and deliver services, 
there is a displacement of patients into the other's programs. 
And we have seen this in many of the other countries we are in.
    In order to minimize that, to anticipate it and to prevent 
it, we are really moving aggressively over the next few months 
to a shared planning and implementation vision.
    The Global Fund is part of our success and will continue to 
be an integral piece of how we are able to increase our ability 
to impact.
    Ms. Lee. Bottom line is how about our pledge for 3 years?
    Ambassador Goosby. We have been aggressively involved in a 
dialogue over the last few weeks. That dialogue has continued 
through this week. We will come to replenishment next week with 
a proposal that I believe is strongly supported within the 
administration. It has required a new vision and new 
commitments being made on our part----
    Ms. Lee. Dr. Goosby, do you think that the 101 members that 
signed that letter will be strongly supportive of the 
recommendation?
    Ambassador Goosby.  I think that we always appreciate the 
input from our congressional leaders and the insight and wisdom 
that they bestowed on us through that letter was greatly 
appreciated, and all of those issues were taken into account in 
the discussion.
    Ms. Lee. You sound like a lawyer.
    Thank you very much.
    Chairman Berman. They appreciate the 101. We don't know 
whether the 101 appreciate them.
    Ms. Lee. Can I get a response?
    Chairman Berman. By unanimous consent, the gentlelady has 
an additional minute.
    Ambassador Goosby. We are very supportive of that effort. 
We are thrilled that you have committed to giving your time and 
thoughts to this. The connection to health and human rights is 
basic, fundamental, needs to be amplified and we are supportive 
and will be supportive of the committee.
    Dr. Frieden. Similarly, we would be delighted to be 
supportive in any way with our colleagues. I will emphasize one 
area in particular, which is gender-based violence, where CDC 
studies in multiple countries in Africa have shown this, 
particularly intergenerational gender-based violence to be far 
too common and a driving force behind the epidemic. So this is 
one area which is not only a terrible human rights violation 
but also a driver of the epidemic.
    Chairman Berman. The gentleman from Arizona, Mr. Flake, is 
recognized for 5 minutes.
    Mr. Flake. Ambassador Goosby, when the last reauthorization 
came in in 2008, there were several requirements put into law 
in terms of reporting having to do with best practices and 
efficiencies. It is my understanding that those reports have 
not been issued. If not, why not? And how can we be expected to 
reauthorize or appropriate more money without some of the 
requirements having been met?
    Ambassador Goosby. Well, thank you, Congressman Flake. 
Perhaps the central emphasis since I have started this position 
has been to look at, especially in this economic decline, all 
areas that we can engage in to become more efficient, to take 
advantage of synergies and collapsing of resources so they are 
truly additive within the program as well as between the 
programs.
    We have created a process that has canvassed every country 
that we are in. Thirty at a high level, but all 80 countries. 
And we have compiled a strategy that is focused specifically on 
identifying and integrating these strategies into an 
identification of efficiencies that become programmatic and 
entered into our budgetary relationships.
    We have completed a document that I had thought had come to 
you. It has been submitted to the committee, but you obviously 
haven't seen it. We will work with your staff to make sure that 
you get that forthwith.
    Mr. Flake. This will comply, or be responsive to the 
requirements in the 2008 reauthorization?
    Ambassador Goosby. Yes, sir.
    Mr. Flake. I will yield the rest of my time to Congressman 
Smith.
    Mr. Smith. I thank my good friend for yielding.
    If I could just, Dr. Goosby, get an answer. In the 
partnership framework, is the conscience clause included there, 
because obviously, while we are encouraging local control, it 
is never absolute. Obviously, we have parameters. Is it in 
there?
    Secondly, I was at a roundtable last week at the U.N. 
Development Goals Summit at the United Nation run by the 
Rockefeller Foundation and GAIN, and seven first ladies, led by 
Lady Odinga, emphasized the first 1,000 days of life from the 
moment of conception is a wonderful event, which obviously that 
will predict what happens in the next, 25,000 hopefully, days 
of life, if someone can live into the seventies.
    But it was from the moment of conception, it was all about 
good nutrition and it was an affirmation of life before birth, 
that an unborn child is sacred and precious, and birth is just 
an event that happens to all of us. It's not just the beginning 
of life.
    I would note the next day the Secretary of State was at a 
similar unveiling with the foreign minister of Ireland during 
which she wouldn't say the words ``moment of conception.'' 
Okay. That is unfortunate. But it is still the same idea. Those 
first 1,000 days are absolutely crucial. And with PEPFAR, Don 
Payne was very emphatic on this, as was I, as chairman and 
ranking member of the Africa Subcommittee, that nutrition is 
crucial to PEPFAR.
    It is contradictory to me that on the one hand, Global Fund 
is talking about reproductive health including the killing of 
the unborn child by way of abortion, and we are also talking 
about nutrition and providing protection and all the possible 
enforcement backstopping for that baby in the first 1,000 days.
    Finally, behavior modification, and I assume that is A and 
B of the ABC model. Doctor Eliodo--head of the Ugandan member 
of parliament--has said very clearly that the B is so 
important--A is important--but the B is so important. When 
there are multiple concurrent partners, the epidemic continues 
to spread notwithstanding perhaps ARVs. So what about the 
emphasis on the B?
    But if you could get into the conscience clause first.
    Ambassador Goosby. Yes, Congressman.
    The partnership framework is an attempt to engage in a new 
dialogue with country to establish a commitment to relative 
contributions from our partner country as well as the United 
States Government over a 5-year period. It is under the PEPFAR 
legislation, and the conscience clause does apply to that 
dialogue. In terms of the Global Fund and the chart that you 
mentioned----
    Mr. Smith. Is it binding or is it just part of the 
dialogue?
    Ambassador Goosby. We legislatively are bound by the 
conscience clause legally so we cannot agree to something that 
is outside of the parameter.
    Chairman Berman. The gentleman from North Carolina, Mr. 
Miller, is recognized for 5 minutes.
    Mr. Miller. Thank you, Mr. Chairman.
    I think all of you have spoken of pediatric HIV/AIDS. And I 
have been stunned when I traveled in Uganda on a congressional 
delegation 3 years ago at how pervasive transmission from 
mother to child is very rarely in the United States and very 
common in the developing world. It certainly makes the goal of 
eliminating all pediatric HIV by 2015 look to be an enormous 
task.
    And the precautions that are routine that are universal in 
the United States are almost unheard of in other parts of the 
world, and as a result, thousands of children every year begin 
life with HIV, either born with it or through contracting it 
through breast feeding. The routine precautions beginning with 
the testing of pregnant women with HIV is almost unheard of 
almost all the way through.
    What are the barriers? Is it all the amount of resources? 
Are there other barriers? What stands between us and having the 
transmission of HIV to children from their mothers is as rare 
in other parts of the world as it is in the United States? Dr. 
Frieden?
    Dr. Frieden. Thank you very much, Congressman Miller.
    It is a great question, and I think this is an area where 
we are poised--we have had a lot of progress in the last couple 
of years and we are poised to have even more progress. We have 
countries that now have moved to a universal screening for HIV 
and pregnancy. So we are seeing a substantial scale-up of 
effective prevention.
    There are a series of barriers. First, in some countries 
the proportion of women who give birth in an institution or are 
attended is in the single digits. So when you have a service 
delivery gap that is that large, it shows you some of the 
limitations of a program that is within the envelope of HIV 
only. That is one of the reasons why we think the global 
initiative will actually greatly strengthen not only health 
systems but also HIV prevention and prevention in terms of the 
mother-to-child transmission. But there has been tremendous 
progress in recent years, testing more women, getting more 
women on treatment, getting the children appropriately cared 
for.
    The second key issue is the effectiveness of treatments. 
Some of the regiments require the women to take medications and 
take additional medications during delivery. But if that 
delivery is not attended because, for example, of co-payment 
charges at institutions, then the investment that we have had 
to protect that child is not fulfilled really and the child 
becomes infected.
    So there are ways that we need to change the way women are 
cared for and focus on women getting care before, during and 
after pregnancy. There is also the challenge of breast feeding 
and reducing the risk during breast feeding. And there are some 
real challenges there in terms of the women's experience. The 
data from this comes from trials led by both CDC and NIH, and I 
think it is a success area, but one where I think we need more 
progress.
    Dr. Fauci. I agree completely with Dr. Frieden's 
assessment. I think it also underscores what we were saying 
before about the penetration into the community of getting 
people tested and treated. We need to think not only that we 
have to prevent transmission to the baby, but also that we have 
to treat the mother as an individual, and then you will do two 
things: You will prevent transmission to the child, and you 
will also prevent transmission through breast feeding.
    As Dr. Frieden said, really the opportunity is 
extraordinary. The more people we test, the more people we 
treat. Among those will be women who either will be pregnant or 
are pregnant, and then you have the secondary benefit of 
preventing the transmission to the child.
    Mr. Miller. Similarly there have been--the other parts of 
the world lag well behind in early diagnosis of children with 
HIV. What are the barriers to earlier diagnosis and therefore 
earlier treatment?
    Dr. Frieden. We have been delighted to be able to work with 
a series of African countries to build up a capacity for early 
infant diagnosis, and I was delighted to see, for example, in 
Mozambique, the reference laboratory using the text messaging 
technologies secure through return results very rapidly so that 
children, infants, could get on treatment. And that kind of 
innovation is what we hope to see more of, getting cutting-edge 
laboratory services through dried blood spot and then getting 
the results back to the treating physician right away so that 
they can start treatment rapidly right away if needed. That 
early infant diagnosis is also very important. Has a quality 
assurance mechanism. We know we are treating women, testing 
women, but are we preventing transmission? And that is a 
critical mission for us.
    Ambassador Goosby. If I could just add an anecdote to that. 
The remarkable moment at birth and having the child there and 
having to wait for antibody production over an 18-month to 2-
year period has been preempted with the ability of early infant 
diagnosis. And PEPFAR is committed to expanding that capability 
in all of our programs to allow individual children to get on 
both cotrimoxazole as well as antiretrovirals at birth.
    Chairman Berman. The gentlelady from California, Ms. 
Woolsey, is recognized for minutes.
    Ms. Woolsey. Thank you, Mr. Chairman, and thank you to the 
panel. I want to take this just one step further and then I 
have another question to ask also.
    So when women are unable to obtain family planning 
information and the appropriate prevention methods, NuvaRing, 
shots, condoms, because of the complications that come along 
with the conscience clause, or maybe that doesn't happen, tell 
me if I am wrong. But when we make it difficult for women to 
prevent pregnancy in the first place, and quite often that 
would prevent AIDS and HIV with the appropriate prevention 
products, what impact does that have on HIV/AIDS and the 
numbers before we start treating it?
    Ambassador Goosby. Well, I can take an attempt at that. It 
is a difficult question. It is a good question. We have been 
very aggressive at talking with our partners who we are engaged 
with at the country level to understand their concerns around 
making available a referral mechanism to family planning 
reproductive health services. That usually is doable. And it is 
a commitment on part of the institution itself who has 
difficulty moving forward with those services on their own 
site, but allowing the patient in front of them with that 
immediate need to be addressed and referred in a seamless way 
is our goal.
    We have been able to engage in that in most every instance 
that it has come up, and will continue to honor both the 
conscience clause in that effort, but also being clear that our 
real responsibility to the patient in front of us is to respond 
to her needs. Thank you.
    Ms. Woolsey. Speaking about her needs, without taking 
anything away from HIV/AIDS support and investment, both from 
the United States and internationally, what would it take for 
this same group of partners to invest in maternal mortality and 
child mortality at the same time? I mean, my goal is not to 
take anything away from the successful HIV programs, but to 
build on that and to go into the next level of maternal health.
    Ambassador Goosby. I will take the first attempt at that. 
We are thinking alike. President Obama's Global Health 
Initiative is an attempt to do just that, to take the 
successful programming that we already have in place--in this 
instance HIV/AIDS--to use that robust medical platform to build 
onto, to add to, services that allow the same patient with HIV 
in front of us who has needs in maternal and child health, 
family planning, neglected tropical diseases, immunizations for 
the children, other family members, as well as a package of 
essential services for hypertension, diabetes, whatever, 
defined by each country, this is an attempt to do just that. 
Build on the platform that is already in place, to expand the 
services that are needed by the population that we have already 
captured.
    Ms. Woolsey. Dr. Frieden, I am not suggesting that we take 
the same pot of money, and then expand the services and I am 
also suggesting that there are women, and young women, that 
don't have HIV. So how do we get to them and set up--I don't 
want it to only be women who are already infected.
    Dr. Frieden. Through the PEPFAR support we have been able 
to strengthen health systems; we have been able to improve the 
quality of delivery; we have been able to increase access to 
emergency obstetrical care, and this is critically important 
for HIV prevention, and also to support women's health and 
child health. And I think, you can see an evolution from the 
PEPFAR reauthorization, which enables us to strengthen systems 
more comprehensively, so that we would not only have a more 
sustainable way of achieving the outcomes of PEPFAR, but also 
improve other health conditions through the Global Health 
Initiative, where we are saying we are going to take all of our 
investments we know that we are in a scarce resource 
environment, we know that every dollar is precious, and we are 
going to stretch each of them as far as we can by having the 
services that are available as efficiently and as close to the 
client as possible.
    Ms. Woolsey. Dr. Fauci, before you answer, try to add into 
if this were a perfect world, and we really cared about 
children and their mothers, what would it take from the United 
States?
    Chairman Berman. By unanimous consent, the gentlelady has 1 
minute--not until we have a perfect world.
    Dr. Fauci. I can do it in less than one.
    In fact, Congresswoman, that is exactly what the 
fundamental philosophy and strategy of the President's Global 
Health Initiative is--exactly what you are saying. PEPFAR is a 
major component of that, but within the Global Health 
Initiative is exactly what you are referring to, not only have 
both an independent as well as interdigitating approach toward 
women's health and child mortality but also have it something 
that has its own force and its own life apart from PEPFAR.
    But they are so closely joined, that you can almost not 
separate them.
    Ms. Woolsey. Thank you very much, Mr. Chairman.
    Chairman Berman. Time of the gentlelady has expired. The 
gentleman from Minnesota, Mr. Ellison, is recognized for 5 
minutes.
    Mr. Ellison. Mr. Chair, thank you for this really important 
hearing and thank you to our witnesses.
    Could you talk about the issue about the scarcity that you 
mentioned a moment ago? I am curious to know how are our 
country partners addressing and augmenting the battle to 
overcome AIDS and HIV? Are we seeing legislatures from the 
countries that we are partnering with appropriating money to 
the degree that can handle some of the outyear cost associated 
with the ARTs and so? Could you address this?
    Ambassador Goosby. Thank you, Congressman. It is an 
excellent question.
    Our whole approach with the partnership framework is to 
engage in a different dialogue with each country around the 
human resources, the financial resources, the administrative 
resources that are needed to continue a specific outline of 
programs that the partner government is contributing to and the 
United States Government is contributing to.
    Over a 5-year period, we define it explicitly and include 
in that an expectation and time line around commitments.
    The dialogue is with country leadership. That leadership 
has largely been central with the Ministry of Health, but the 
Minister of Finance comes into it eventually always. The 
President frequently blesses it and/or signs it. We have had 
multiple, in every country that I go to, I meet with 
leadership, including legislative appropriators, and have had 
difficult discussions around relative contributions on a 
financial level to this effort.
    Nigeria is a good example of this. Deputy Secretary Lew and 
myself went to Nigeria and in addition to looking at programs, 
we met with the President, with the Appropriations Committee, 
with legislative leadership on multiple party levels. We have 
also met at the provincial level with leadership as well.
    All of it was a discussion around what can we expect in a 
country with an emerging economy, such as Nigeria, to assume in 
the monetary support of these services. Again, remaining 
committed to administrative and continued support on part of 
the United States, it was the first time we got into an 
explicit dialogue around what portion of that monetary 
allotment can you realistically begin to assume for yourself.
    Nigeria came in within at the end of their 5-year period 
that they would assume 50 percent of the cost. That was a huge 
increase from where they are currently, and a sincere 
commitment made by both appropriators and the President.
    Mr. Ellison. I am glad you all have that conversation 
because I think it could have some benefits to other health 
challenges that a lot of other emerging countries are facing. 
If you can develop a system to address HIV/AIDS, you can do 
that, perhaps, for malaria and other things.
    Let me ask you this much, too. How much input do partner 
countries have into how we are appropriating PEPFAR dollars in 
their own country? I have had a chance to spend some time in 
Kenya and learned they have more deaths from malaria than they 
do from HIV--of course, both are serious problems. But talk to 
me about how much input our partner countries have into 
directing how PEPFAR resources are allocated?
    Ambassador Goosby. I will very quickly say that our initial 
response with PEPFAR was an emergency response, and we deployed 
largely through NGO continuums of care and services with 
partnered governance and civil society.
    We, in the second phase of PEPFAR, looking at the emergency 
response, moving into now sustained responses, see the need to 
move more aggressively and to a different dialogue with partner 
countries around their relative management, ownership, 
oversight, defining unmet need, prioritizing unmet need, and 
being in and part of the allocation discussion.
    This is in most of our countries a new and expanded 
dialogue for PEPFAR. It is a dialogue that the President and 
the Secretary of State feel very strongly about, I feel very 
strongly about, that this is the conduit through which we will 
really achieve sustainable, durable programming.
    Mr. Ellison. I guess my last question is the U.S. Congress 
is a highly political body. How is that for stating the 
obvious? And people bring their agendas here. Unfortunately 
when it comes to foreign affairs, our agenda gets pressed on 
other people outside of our borders allotted. And when it comes 
to----
    Chairman Berman. The gentleman has an additional minute.
    Mr. Ellison. When it comes to programs like PEPFAR and 
PEPFAR, for example, are there certain things that Members of 
Congress here think are very important to them and maybe 
important to their constituents but that create complications 
when they are translated into the work that you have to do? So, 
for example, well, I'll leave the example out for the moment.
    Ambassador Goosby. It is a an astute question. But an 
understandable dissonance is created with our congressional 
bodies and the constituencies within our Congress moving 
forward in a Congress. We have that same dissonance set up in 
our country dialogue as well because each country is different, 
has different norms and self-expectations that must be 
considered and acknowledged and incorporated into the plan as 
we move forward.
    That sensitivity and where we draw that line is much of 
what our dialogue becomes in the actual final partnership 
framework discussion. We are acutely sensitive to it, but also 
have frames and references that kind of define our parameters 
and how far we can go in both ways.
    So it becomes a dialogue.
    Chairman Berman. The time of the gentleman has expired.
    The gentleman from New Jersey, the chair of the Africa and 
Global Health Subcommittee, Mr. Payne, is recognized for 5 
minutes.
    Mr. Payne. Thank you very much, Mr. Chairman. Let me 
commend you for having a full committee hearing on this very 
important subject. It is so good to see our panelists, Dr. 
Goosby and Dr. Frieden, and who has been a longtime friend from 
New Jersey, Dr. Fauci. We can't think of anything that is more 
important right now as it relates to the developing world. And 
I think that the program of PEPFAR was really a program that 
made many of us very proud, even with the first authorization 
of the $15 billion over 3-year period. This was a quantum leap 
from what we had been funding.
    As you know, funding for HIV/AIDS has--even here in the 
U.S.--gone very slowly, and when it was first diagnosed, in the 
early 1980s, there was only several hundred thousand dollars 
that actually was appropriated over the course of 3 or 4 years 
in the 1980s, where we simply allowed this to fester and 
continue. There was very little attention given.
    So we have continually commended President Bush when the 
notion of increasing the PEPFAR program--of course, we had the 
majority in the House, but we did need the cooperation from the 
White House and the President did agree to double it from $15 
billion, and I was advocating with them. But then I thought if 
he was willing to go along with $30 billion, that that wasn't 
enough. So we pushed the $50 billion number, and we were able 
to get a $48 billion reauthorization, which I think was one of 
the greatest marks of our country's foreign assistance program 
in its history, and has done so much to save so many lives.
    I know they have been recognized, but I understand the 24 
women from Parliament, and several First Ladies from Ethiopia, 
and Deputy Prime Minister of Zimbabwe are here. It is great to 
have you here in the audience. I look forward to meeting with 
you later in the day.
    Let me ask, Ambassador Goosby, we do know that you need to 
have the participation and cooperation from local people to 
move this program forward, and anyone can chime in.
    But specifically, let me ask you, what is the role of 
local, national, and international nongovernmental 
organizations and civil society in designing and implementing 
the PEPFAR program? Just how much are they engaged on the 
ground and so forth?
    Ambassador Goosby. Congressman Payne, let me first say 
thank you for your leadership, longstanding leadership in this 
arena, both domestically and internationally.
    We have seen an emergency response in PEPFAR move to a 
sustained response. We are scrambling now to implement that 
shift from emergency to sustainable. It brings in country 
ownership. The country ownership aspect includes government as 
well as civil society. And I would include certainly the NGO 
community as an integral part of that civil society component.
    We feel that they have and will continue to play the 
critical role in prioritizing and defining our implementation 
needs with the dialogue in our partner countries.
    The final role that we seek to complete and improve the 
chances of sustainable durable program is to work in civil 
society, to establish a voice that is in and amongst those who 
use the services to give feedback to allocators and 
appropriators around the appropriateness of their allocation. 
When you keep that dialogue present, and when you create a safe 
space for that dialogue to occur, the program becomes self-
correcting. When you don't, it is ephemeral and fragile. So we 
are committed to that third component.
    Mr. Payne. Thank you very much.
    Let me just ask this last question before my time expires.
    The good news is that HIV-infected persons with either 
latent TB infections or active TB can be effectively treated. 
It would maybe be Dr. Frieden or Dr. Fauci who would want to 
answer. How is PEPFAR aggressively addressing the TB/HIV co-
infection issue?
    Chairman Berman. Without objection, the gentleman has 1 
additional minute.
    Mr. Payne. Thank you, Mr. Chairman.
    As you may recall, about 4 or 5 years ago, we found in 
South Africa about 53 or 54 persons who had the virus, Bishop 
Desmond Tutu wrote a letter that when the infection of the TB 
came through, 53 of the 54 people died within several weeks. So 
I wonder if you could respond to that in the time that I have 
left.
    Dr. Frieden. Thank you. I will try to summarize my 10-15 
years working in tuberculosis control globally in the next 30 
seconds.
    Fundamentally, it is a question of good management and 
significant PEPFAR resources are going into improving the 
management of tuberculosis. Many of the countries in Africa had 
functioning tuberculosis-control systems, but when HIV came in 
and tripled the number of cases they were overwhelmed.
    The most effective way we can reduce TB is to scale-up 
treatment for HIV at this point because that drives down 
numbers, but often, TB comes before we treat at the current 
guidelines. So the challenge is to make sure that the patients 
are promptly treated and fully treated and we work closely with 
countries throughout Africa to improve their treatment systems 
and improve the ability to diagnose and ultimately treat the 
resistant forms of drug-resistant forms of tuberculosis.
    What we do hope is that by scaling up effective treatment, 
we can prevent that in the first place.
    Chairman Berman. The time of the gentleman has expired.
    We don't often get the three of you here together so that 
we are going to allow Mr. Smith and then Ms. Lee to each have 1 
minute for a last question and answer.
    Mr. Smith. Because of time, some of the questions were 
unanswered. Dr. Goosby, again, the Board of the Global Fund 
talks about funding abortion. Is that the administration's 
view? And secondly what priority is given to A and B, the 
abstinence and be-faithful part of the ABC model?
    Ambassador Goosby. Congressman Smith, I really have to say 
I need to look at that because that will be something that we 
would want to understand better and we will definitely get back 
to you on that in terms of what the Global Fund is saying.
    In terms of what the commitment to our conscience clause 
and the abstinence and being faithful. The abstinence and being 
faithful, we continue to fund at high levels, and I would be 
very happy to go over it in great detail with you country by 
country, the abstinence and be faithful efforts. And as I said 
in the previous question, we had linked referral mechanisms so 
services that are needed that fall out of the abstinence and be 
faithful response can be addressed as well.
    Chairman Berman. The time of the gentleman has expired. The 
gentlelady from California, 1 minute.
    Ms. Lee. Let me just say when we were in Vienna, there was 
a lot of discussion about men having sex with men and how they 
are 19 times more likely to be living with HIV other than the 
general population. So what are we doing to ensure that 
countries are actually attempting to provide services to this 
vulnerable population without stigmatizing or jeopardizing the 
privacy and safety of these individuals?
    Ambassador Goosby. It is a very good question, 
Congresswoman, in terms of in a high interest and focus for 
PEPFAR.
    Men who have sex with men are complicated in sub-Saharan 
Africa. For example, in Malawi, 67 percent of the men who have 
sex with men are married. They have families. And they perceive 
themselves in the community and present themselves in the 
community as heterosexual. That kind of stigma that pushes that 
revealing oneself to family and community down is something 
that PEPFAR has attempted to develop unique strategies that are 
different in each neighborhood and each region to try to create 
safe spaces so an individual can indeed access services.
    We also have a diplomatic component that engages in 
dialogue at the Presidential level and at legislative levels in 
country to express concern with legislative responses to 
behavior patterns that are unacceptable in the country but have 
criminal associated consequences for them. And we are engaged 
in multiple countries on that front.
    Chairman Berman. The time of the gentlelady has expired. I 
want to thank all of you very much for making time in your 
schedules to be here today, and I appreciate all you are doing 
in this effort and your leadership, and thank you. 
    We now have a second panel, people right out there in the 
field. If the two witnesses could come up.
    Paula Akugizibwe is a citizen of Rwanda, is currently based 
in Cape Town as the advocacy coordinator at the AIDS and rights 
alliance for South Africa. ARASA conducts training and self-
advocacy in the southern region to improve access to TB, HIV 
services and to advance a human rights base response to health.
    Dr. Wafaa El-Sadr is professor of medicine and epidemiology 
at Columbia University, the director of the International 
Center for AIDS care and treatment programs, and the director 
of the Global Health Initiative at Columbia University's 
Mailman's School of Public Health. ICAP, the center she founded 
and currently directs, works in 14 countries in sub-Saharan 
Africa in partnership with governmental and nongovernmental 
organizations building in-country capacity for HIV prevention 
care and treatment.
    We are delighted to have you with us this morning. And we 
look forward to your testimony. Your entire statements will be 
included in the record.
    Ms. Akugizibwe.

 STATEMENT OF MS. PAULA AKUGIZIBWE, ADVOCACY COORDINATOR, AIDS 
        AND RIGHTS ALLIANCE FOR SOUTHERN AFRICA (ARASA)

    Ms. Akugizbwe. Mr. Chairman, committee members and 
distinguished guests, good morning and thank you for this 
invitation to testify before one of the most historically 
significant committees on global policy on what is probably the 
most significant issue on global health.
    The establishment of PEPFAR in 2003 represented an 
unprecedented response by the United States to a global health 
problem which had far-reaching implications with development. 
The founder of the U.N. AIDS wrote that PEPFAR changed the 
landscape elevating AIDS issues to one of the big political 
themes of our time.
    In 2008, under the leadership of this committee, you 
enhanced that commitment with the visionary Lantos-Hyde Act 
which set forth a ground-breaking direction for the future of 
global HIV funding and helped to significantly strengthen our 
resolve to fight HIV in African countries. As the Lantos 
Foundation previously stated, to some, HIV treatment and 
prevention is seen as a burden on the U.S. taxpayer. Instead, 
it should be seen as an investment that has already paid for 
itself many times over in goodwill toward our country and hope 
restored in African communities.
    There is no question that PEPFAR has great erased the 
stigma in the African region and rightly so. It remains an 
initiative for which millions of people across the continent 
are grateful, an unquestionable investment in public perception 
of the U.S. enhancing global security.
    It is critical to acknowledge from the outset that the 
value of PEPFAR is not limited to dollars, cents, and public 
health statistics, but extends to significant political impact.
    The political world resources that were mobilized by the 
U.S. for the fight against HIV reverberates across the world at 
a time when AIDS was estimated to be decreasing the TDB of 
high-prevalence countries in Africa by an average of 1.5 
percent per year. Increased investment in HIV gave us an 
opportunity to bend these economic and epidemic curves which 
has led us to where we are today--at a tipping point for global 
health, balancing precariously between the good news and the 
bad news.
    The good news, which we have heard this morning, is that we 
are not fighting a losing battle. There is ample evidence that 
we are bending the curves, that the once illusive dream of an 
HIV-free generation is eminently achievable changing the 
question from ``can we?'' to ``do we want to?''
    The bad news is that without increased resources now, our 
chance to defeat HIV must slip from our grasp and the climate 
of AIDS could return. It would be tragic for this to happen in 
the context of some of the most encouraging leaders in the 
history of the HIV epidemic, which we have heard in the past 
couple of years and we have heard this morning as well that 
AIDS deaths are declining globally for the first time since 
2007. The HIV incidents is declining especially in sub-Saharan 
Africa, and that treatment has turned out to be a most 
effective biomedical prevention tool.
    A U.S.-funded study as was cited earlier showed that 
treatment reduces the transmission of HIV by approximately 90 
percent with incredible long-term cost saving potential.
    Modeling studies presented at the Vienna Conference 
indicated that universal access in South Africa, if fully 
funded today, would result in a 17 percent reduction of 
transmission over 3 years achieving cost break even in the same 
space of time.
    In the time of economic crisis, it is politically and 
financially expedient to look to short-term savings, but long-
term social economic rationale tells us that greater investment 
now will mean smaller expenditure down the line. This has 
already been retrospectively validated by data released this 
month from one of the largest PEPFAR-funded treatment sites in 
South Africa, which demonstrated even further cost savings 
associated with an incredible impact of ARV therapy on boosting 
our response to other health challenges such as TB and maternal 
and child health.
    On maternal and child health, earlier this year HIV was 
described by The Lancet, the world's leading medical journal, 
as the greatest cause of paralysis in efforts to address 
maternal and child mortality in sub-Saharan Africa, a paralysis 
that has been alleviated by PEPFAR's provision of ARV services 
to at least 1.7 million women and children in the region, as 
well as a provision of prevention and testing services to 
millions more.
    An analysis that I got from the Journal of AIDS last year, 
which I will be happy to share with you, also demonstrated the 
scale-up of ARC has increased access to reproductive health 
services across the board--not just women living with HIV.
    President's Obama's Global Health Initiative is welcome in 
its recognition of the need for comprehensive package of health 
services and an increased focus in maternal and child health. 
However, the lack of a sufficient correlating increase in 
funding to support this expansion, such as the fulfillment that 
will come at the cost of HIV, TB, and malaria programs. Any 
slackening of efforts to scale-up HIV treatment will scale back 
progress in all other areas of health and development 
identified as a priority by the GHI and will push us toward a 
loss at a time when we are more poised than ever to win.
    Unfortunately, the trend toward flatlining PEPFAR funding 
has already begun to do this. The Global Fund rotation 
requested by President Obama was $50 million less than what was 
given last year, and even with the current known level of $1.1 
billion, still falls far short of the $2 billion per year that 
was authorized by the Lantos-Hyde legislation.
    We are not worried about money for its own sake but the 
impact of these financing decisions on our communities. We are 
worried that given these trends of flatlining, the 2009 
directive to Uganda PEPFAR centers is namely that new patients 
could only be enrolled when others died or lost a follow-up 
might be repeated elsewhere in the future and wreak similar 
havoc.
    Doctors Without Borders has already reported increasing 
treatment of migrants at many of its sites in Mozambique where 
it notes that PEPFAR has warned of an annual 10-15 percent 
reduction in the ARV supplies over the next 4 years. Similar 
concerns have been reported in other countries.
    These developments seriously threaten to undo our progress 
in the fight against HIV. I would like to emphasize that we, of 
course, appreciate that the U.S. cannot do it alone. Advocacy 
and increased funding has been directed to a wide variety of 
governments. However, we do have to recognize that much like 
the establishment of PEPFAR changed the landscape of global 
AIDS response for the better, so the current slackening of U.S. 
Government efforts on scaling up HIV treatment is leading a 
regression back to the landscape where HIV was a death sentence 
because the price tag of life was deemed too high by 
governments.
    But the longer-term price tag will be even greater. The 
World Bank warned us last year that responding to immediate 
fiscal pressure by reducing spending on HIV treatment and 
prevention will reverse recent gains and require costly 
offsetting measures over the long term. It would be sad to see 
this come at a time when we are poised to turn the tide and 
when advocacy to hold national governments accountable for 
their contribution to the fight against AIDS is rapidly gaining 
momentum.
    In the African region over the past 15 months, civil 
society organizations have intensified efforts to scrutinize 
government budgets and expenditure and advocate for increased 
transparency and accountability.
    Yesterday, more than a dozen countries across the region 
took part in the first ever regional day of action on health 
funding. Thousands of people took to the streets in public 
demonstrations, health press conferences and public meetings 
all geared as calling on our governments to increase the 
domestic investment in helping, including HIV treatment, and as 
global leaders to fully replenish the Global Fund.
    This advocacy drew in a remarkable variety of partners 
under the leadership of NGOs working on HIV, thus demonstrating 
that the extensive community networks and movements that have 
been created through the HIV response present extraordinary 
platforms for mobilization and national government 
accountability, which will be severely undercut if funding 
retreat persists.
    We also note that we have seen positive government response 
from countries around the region. For example, in Kenya the 
2010-2011 budget for HIV treatment has doubled compared to the 
previous year due in large part to the Kenya PEPFAR partnership 
framework. In South Africa, the HIV budget showed a 3 percent 
increase this year. Following advocacy in Swaziland earlier 
this year, the government exempted the Ministry of Health from 
a sweeping budget that affected all other sectors. And we have 
heard earlier from Ambassador Goosby about the positive 
developments in Nigeria.
    Some of the poorest countries in the regions, such as 
Rwanda, Malawi, and Tanzania are leading the region when it 
comes to the domestic investment in health. Rwanda and Botswana 
are two of only eight countries in the world where universal 
access to treatment has been achieved.
    All of this goes to show that the vision originally 
embraced by this committee with establishment of PEPFAR and the 
Lantos-Hyde legislation is entirely attainable but the key to 
determine success as we move ahead is political will.
    The crucial bottlenecks that we face with the future 
progress in the fight against HIV are not related to economics 
or to science but to political priorities. When the Lantos-Hyde 
Act was passed 2 years ago, you took a very definitive landmark 
step toward realigning these political priorities and gave 
people living with HIV all around the world, as well as the 
communities, great hope that finally, a lasting precedent had 
been set for an energized global response to HIV, which would 
set the tone for a much broader response from all countries, 
and influence responses to other health needs as well. This has 
already been seen.
    Next week as mentioned earlier, donors will meet in New 
York to determine the fate of the Global Fund which requires a 
minimum of $20 billion U.S. dollars over the next 20 years. The 
United States could transform the replenishment with a promise 
of a bold 3-year pledge at the levels authorized through 
Lantos-Hyde of up to $2 billion per year.
    I am here today to urge you to make this happen or to help 
make this happen, and best meet global efforts to making 
history by winning the fight against AIDS.
    Third, as you move toward a more long-term strategy for 
PEPFAR, it is my hope that you will recognize that 
sustainability will be achieved not by relaxation, but rather 
by intensification of efforts and investment because while this 
might cost us more today, evidence clearly shows that it will 
save us much more tomorrow. And that is the true basis of 
sustainable development.
    So I hope this committee will help us make a decision for 
tomorrow.
    Thank you.
    [The prepared statement of Ms. Akugizbwe follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Chairman Berman. Thank you for reminding us of the dangers 
of backsliding.
    Dr. El-Sadr.

      STATEMENT OF WAFAA EL-SADR, M.D., M.P.H., DIRECTOR, 
   INTERNATIONAL CENTER FOR AIDS CARE AND TREATMENT PROGRAMS 
  (ICAP), MAILMAN SCHOOL OF PUBLIC HEALTH, COLUMBIA UNIVERSITY

    Dr. El-Sadr. Good morning, and thank you for the 
opportunity to testify today at this very important hearing.
    I have personally been working in the field of HIV medicine 
since the very beginning of the epidemic when I was working at 
Harlem Hospital in New York City. And over the past decade, I 
have spent a great deal of my time working on PEPFAR-supported 
HIV and related capacity building, program development, and 
implementation in sub-Saharan Africa.
    As mentioned, I serve as director of ICAP, which is 
situated at Columbia's Mailman School of Public Health, an 
institution with a long history of work, not just in HIV, but 
also in maternal mortality and child health.
    ICAP is a PEPFAR-implementing partner that supports more 
than 1,200 health systems in 15 countries in Africa today, and 
to date, it has supported services for over one million HIV-
infected adults and children in a family-focused, women-
centered approach. Roughly half of these individuals have 
initiated treatment. More than a million pregnant women with 
HIV have received HIV care for their own health, as well as 
prevention of transmission to their babies. Other supports 
include integration of TB/HIV services, HIV testing counseling, 
laboratory support, amongst many others. It has also supported 
the dynamic evaluation methods to inform programs and to ensure 
quality of the programs.
    We have witnessed firsthand the impact of PEPFAR on 
individuals, families, and communities, the rapid expansion of 
host country capacity, and the remarkable goodwill generated by 
PEPFAR for the U.S. and its people. Yet the work is far from 
done. The success of PEPFAR is widely acknowledged by the 
millions who have benefited from its program. Thus it is 
sometimes puzzling when one hears some misunderstandings 
regarding PEPFAR. I will briefly address these through the 
lense of my own experience and observations.
    First, some claim that PEPFAR works in isolation 
disconnected from country ownership. My experience says 
otherwise. PEPFAR is demand-driven at the community and host 
government levels. The work has been planned and implemented in 
partnership with Ministries of Health, regional district and 
facility health teams, as well as nongovernmental 
organizations, including faith-based organizations and with the 
affected communities.
    PEPFAR implementers play important and complementary roles 
in the scale-up of these programs, all contributing to the 
national AIDS control programs developed within the countries 
themselves. U.S. agencies, such as CDC and USAID, play key 
roles in forming these efforts under other coordination and 
guidance.
    Second, some claim that PEPFAR-supported programs have been 
developed as separate and distinct services in silos that are 
not integrated and linked to established services within the 
countries. Again, my own experience differs from this 
perception. The majority of health facilities deliver 
integrated HIV and primary care services right where these 
services are provided, including linkages to other key services 
such as reproductive health.
    In Nigeria, for example, ICAP supports PMTCT services for 
pregnant women within existing antenatal clinics. In Rwanda, 
ICAP in collaboration with the Rwandan Government, has 
supported integration of TB and HIV services and synergies 
between these two programs.
    In Ethiopia, in collaboration with the regional health 
bureaus, ICAP supports scale-up of routine HIV screening for 
all in-patients and out-patients at health facilities, 
including testing of mothers and babies integrated in 
immunization clinics. And there are many, many other examples.
    Fundamentally on the ground, there is no distinction 
between Global Fund and PEPFAR funding. The inputs are all 
integrated at the delivery site.
    Third, some claim that PEPFAR has had limited contributions 
to the country's health systems, but the evidence says 
otherwise. In many of the countries where ICAP works, it has 
supported the development of tiered laboratory systems as we 
heard before. Good national regional local laboratories provide 
training and mentorship to staff. Health work toward 
innovations have also built up on the skills and morale of tens 
of thousands of existing health care workers in new countries 
through training and mentorship.
    Pharmacies across the continent have been supported through 
the provision of infrastructure, training, mentorship, capacity 
building for stock management and many, many other inputs--all 
of them contributing to stronger health systems that can 
respond to HIV as well as to all other health threats.
    A fourth misconception is that evidence of PEPFAR's impact 
is difficult to discern. In reality, a key attribute of PEPFAR 
is its focus on concrete measurable outcomes, an approach that 
should serve as a model for other health and development 
programs. Without a doubt, PEPFAR has saved millions of lives 
and has preserved families and communities through access to 
HIV treatment. More than 7 million pregnant women have received 
counseling and treatment to prevent HIV transmission.
    Expansion of prevention counseling programs for male 
circumcision for HIV prevention are taking off in several 
countries. Overall, there is encouraging information indicating 
a 25 percent decrease in new HIV infections.
    Remarkably, with the expansion of HIV treatment, we are now 
witnessing a decrease in death rates in the most severely 
affected countries, including South Africa and Botswana. 
Different contributions to other health outcomes beyond HIV can 
also be noted. ICAP-supported programs in Nigeria offer 
pregnant women insecticide-treated bed nets for malaria 
prevention, water purification systems and ``mama packs'' to 
encourage safe pregnancy and facility-based deliveries thus 
impacting maternal and child health.
    Renovation of antenatal clinics, labor and delivery wards 
in support of orphans and vulnerable children are just a few 
examples of the broad impact of PEPFAR on the health of 
children.
    Encouraging evidence from South Africa shows a decrease in 
under five child deaths with expansion of HIV treatment to 
women in one community.
    But we are at a critical point in the response to the HIV 
epidemic. Scale-up of HIV treatment in PEPFAR-focused countries 
has been phenomenal, but it has only reached about a third of 
those in urgent need. Desperately ill men, women, and children 
living in communities near and far continue to line up at 
clinics in urgent need of services. For these individuals, the 
emergency is far from over.
    In addition, the more we learn about HIV, the clearer it 
becomes that earlier diagnosis and earlier treatment is more 
successful, and most importantly, more cost effective.
    New WHO guidelines support earlier treatment for adults, 
and it is now recommended that all children with HIV receive 
treatment. Similarly, a global consensus has arisen that all 
pregnant HIV-infected women must be reached if we are to 
eliminate HIV.
    There is also evidence that treatment for persons with HIV 
can prevent them from developing tuberculosis, a leading 
complication. Here is a chance to impact the TB epidemic in 
countries hit hard by the dual epidemics of HIV and TB. 
However, despite the scientific evidence, some national 
programs are reluctant to expand HIV treatments and the 
achievements of all of these benefits are outdone due to 
resource constraints.
    Another critical need is to scale-up evidence-based 
prevention programs, as well as to engage marginalized groups 
like men who have sex with men, injection drug users and 
commercial sex workers in both care and prevention services. 
Recent guidance from OGAC in terms of emphasis on addressing 
gender equity and support for harm reduction, including syringe 
exchange programs, go a long way to reinvigorating HIV 
prevention efforts.
    Thus, we are poised now with many of the new tools that you 
heard about earlier today to have a profound impact on stemming 
the epidemic and preventing new infections.
    There is little doubt that PEPFAR can and does provide a 
platform for addressing some of the key priorities of President 
Obama's Global Health Initiative. Rather than reinventing the 
wheel or starting from zero, we can build on the platform 
established by PEPFAR at the tens of thousands of health 
facilities and under partnerships already established within 
the many communities.
    However, if we stall the expansion of PEPFAR in the name of 
a greater balance in global health spending, then we risk 
limiting advances in maternal and child survival as well as 
many other advances that go beyond HIV/AIDS per se.
    This committee envisioned a scale-up of resources when it 
reauthorized PEPFAR and set bold targets and new policies that 
would move us toward a world without an AIDS crisis. But the 
potential to truly turn the tide against the HIV epidemic and 
to achieving the durable impact, we all desire will not be 
realized if current funding crisis is not addressed. People 
will be turned away from clinics, services will be rationed, 
women and children and their families will suffer. The optimism 
we have witnessed will evaporate and this remarkable potential 
will be squandered.
    Time is of the essence. The sooner we continue the scale-
1up of HIV treatment and prevention, the more lives will be 
saved, the more tuberculosis cases can be prevented, the more 
families, communities and livelihoods will be preserved. 
Greater investments aiming at universal access, continued 
commitment to research in conjunction with an emphasis on 
building capacity and meaningful partnerships can change the 
trajectory of the HIV epidemic in the most severely-affected 
countries. It can also contribute substantially to the overall 
health and well-being of women and children and communities.
    Strong U.S. leadership and partnership with the affected 
countries and communities, as well as other donor nations can 
bring this goal within our reach.
    Thank you.
    [The prepared statement of Dr. El-Sadr follows:]

    
    
    
    
    
    
    
    
    
    
    
    
    Chairman Berman. Thank you for that testimony.
    I am now going to recognize Ambassador Watson for 5 
minutes. We are told there will be votes on the House floor in 
the next 10 or 15 minutes. So I think this will be our last 
shot.
    Ms. Watson. Thank you so very much. You did mention in your 
testimony, and I missed the other witnesses, but our 
administration really would like to now focus on women and 
girls. They tend to be victimized more so in many different 
ways you mentioned. What is the common treatments and thinking 
in terms of securing the health and reducing the risk for women 
and girls?
    Dr. El-Sadr. There are many, many opportunities to do that, 
and some of them are ongoing. There clearly is the effort to 
prioritize the needs of women in the context of PEPFAR. For 
example, in the expansion of treatment, almost 60 percent of 
individuals receiving treatment through PEPFAR are women. In 
addition, the expansion of reach for prevention of mother-to-
child transmission in enhancing the potential for a safe 
pregnancy and safe delivery is actually very profound in terms 
of trying to address the needs of these women.
    Lastly, I think the engagement of women in the context, of 
course, of taking care of their own families by providing them 
with all the resources that they need, recognizing that women 
are the central fulcrum for the health of the families 
themselves is also a very important contribution of what--the 
ongoing work of PEPFAR.
    Ms. Watson. I understand that myths are flying all over the 
place, and there are certain beliefs in certain areas of 
Africa, in particular South Africa. And I go often to South 
Africa, but I heard that there is a belief in the southern tip 
that if men had sex with babies, it would relieve them of AIDS.
    What do we have to do--and, you know, women cannot refuse 
their men when they want to have sex. That is a belief in some 
areas. How do we go about changing the way, the old customary 
ways, of believing when it comes to women and girls? And I am 
just wondering what we can do to enhance the obliteration of 
those kinds of cultural mythical beliefs.
    Ms. Akugizibwe. Well, you know. I think one of the reasons 
why HIV--the HIV epidemic was exceptional is because it has 
highlighted a lot of these long-standing cultural challenges. 
And it has really brought in to bear the public health context, 
but underlying that are much more deep-rooted social issues.
    And speaking from my experience in working with an NGO that 
does community training and community advocacy, issues such as 
this are a fundamental component of all the training that we do 
related to HIV, because unless we can address underlying 
dynamics, we can't actually overcome the HIV epidemic.
    And I think that possibly one of the most valuable things 
that the HIV response has brought us is the creation of these 
extensive, far-reaching, community-based networks that give us 
space to start discussing a lot of otherwise issues that would 
otherwise never have had the opportunity to explore.
    But to also touch on the earlier point about women and 
girls and how they fit into this, one of the things that I had 
mentioned is that HIV in South Africa, for example, is the 
cause of more than 40 percent of maternal mortality. And so for 
us to separate these two things can get a bit misleading 
sometimes. And I think what we need to be doing is seeing how 
we can strengthen the value that HIV response has brought to 
efforts to advance women's health while adding resources to us 
to expand, to address a wider range of issues that don't 
necessarily fall within HIV.
    Ms. Watson. The most successful programs that I saw in 
areas of South Africa were the programs where we gave them the 
resources and let them, through their own techniques, deal, and 
they can talk a small amount of money and stretch it. And so I 
believe that we can better serve the people we are targeting 
with our resources by going through the structure that is 
already it socially and culturally.
    I yield back. You have got 30 seconds, Mr. Chairman, to 
give to someone else.
    Chairman Berman. The gentlelady has yielded back. The votes 
have just been called, so we have about 10 more minutes here.
    Can I just arbitrarily say let us take 4 minutes a witness 
rather than 5?
    Mr. Smith, 4 minutes.
    Mr. Smith. Thank you very much.
    Chairman Berman. 4 minutes.
    Mr. Smith. Sorry I missed our distinguished witnesses. I 
was at a press conference with Jim Moran on a child abduction 
case. The chairman was kind enough to place on the calendar 
yesterday a very important resolution that calls for the 
release of American children who have been abducted to Japan. 
So I do apologize for missing that.
    I would ask unanimous consent that the ranking member's 
statement, Ileana Ros-Lehtinen, be included in the record.
    Chairman Berman. Without objection.
    [The prepared statement of Ms. Ros-Lehtinen follows:]

    
    
    
    
    
    
    Mr. Smith. As well as that of Joseph O'Neill and Michael 
Miller, who have transcripts of testimony that----
    Chairman Berman. Will be included.
    Mr. Smith [continuing]. An op-ed that I wrote for the 
Washington Post, and the African First Lady's declaration.
    Chairman Berman. It will all be in there.
    Mr. Smith. I appreciate that.
    Let me just very briefly raise for all my colleagues, I am 
sure our distinguished witnesses know all about this as well, 
the Call for Action at the Millennium Development Summit last 
week. The First Ladies of Africa--there were nine in total, and 
I believe there were seven in the room--I was at the roundtable 
discussion--they made a very, very important contribution, as 
they always do. Part of their statement was good nutrition is a 
requirement, a way to advance the Millennium Development Goals. 
There is a direct link between malnutrition, hunger and 
poverty, MDG 1; child mortality, MDG number 4; maternal health, 
MDG 5; and AIDS and other infectious diseases, MDG number 6. 
Equally important, poor nutrition has a causal effect in 
eliminating achievement of education, MDG 2, and gender 
equality, MGD number 3.
    They went on to say in their declaration, we now know how 
to reduce malnutrition through the life cycle by a number of 
simple, targeted and cost-effective solutions. The critical 
window of opportunity is the 1,000-day period from conception 
to 2 years old. Fortified staples; good infant-feeding 
practices; more nutritious, complementary foods are some of the 
tools available to help permanently break the intergenerational 
cycle of malnutrition. New ways to mobilize business, develop 
agriculture and food security, improved feeding and health 
practices are available. And then they go on in their 
declaration to make a number of very important mutually 
reinforcing statements.
    I am wondering from our distinguished witnesses how you see 
this playing out, because as we did in the last PEPFAR 
reauthorization, we made sure that nutrition was included. I 
mean, I recall once when I was taking antibiotics, and I wasn't 
eating as much, it causes a backlash even from something as 
simple as doxycycline or some other antibiotic. I can only 
imagine with ARVs, on an empty stomach, in a malnourished 
person, how that could not only be difficult, but also 
counterproductive.
    Obviously nutrition is important. But this idea of the 
first 1,000 days from the moment of conception, could you speak 
to that, if you would?
    Dr. El-Sadr. I will start.
    I think from day 1 in terms of implementation of PEPFAR-
supported programs, there had been attention given to nutrition 
and clearly integration of and provision of nutritional 
supplements to individuals who need it, as well as often to 
families of these individuals. So that has been part and parcel 
of the work on the ground.
    In addition, there has also been very innovative programs 
to try to enable people living with HIV and their families to 
support themselves and to grow their own foods. There are some 
very--programs that I am aware of and some of them we have 
supported in terms of income generation and generating food and 
nutrition for the families and for the communities.
    I think that the third point I want to make in terms of 
nutrition is the importance of, obviously, within the PMTCT 
programs, programs for prevention of mother-to-child 
transmission, there are situated right in antenatal care to 
provide counseling to these women regarding nutrition in terms 
of their own health as well as also in terms of feeding of 
their babies after their babies are born.
    So there is a package that includes--that focuses on 
nutrition that is part and parcel of several components of the 
work that we do, whether it be in the PMTCT antenatal setting, 
in the postnatal setting, or just in terms of the ongoing care 
and treatment activities.
    Ms. Akugizibwe. Your question reminds me of a conversation 
we had with the Canadian national AIDS coordinator and someone 
living in a low-income part of Nairobi.
    Chairman Berman. Our problem is the 4 minutes has expired. 
I am sorry to do this, but maybe you can worm it into the next 
answer here.
    The gentlelady from California, Ms. Lee, is recognized for 
4 minutes.
    Ms. Lee. Thank you, Mr. Chairman.
    Let me just say the importance of women's voices and the 
work of women, the empowerment of women is so key to stamping 
HIV and AIDS from the face of the Earth. You both are really 
wonderful examples of why women have to be at the lead in this 
effort, so thank you very much.
    I just wanted to ask you one question about--and I 
mentioned earlier that I was appointed as a Commissioner on the 
Global Commission on HIV and the Law. We will be meeting next 
week in Brazil. I wanted to find out from you in terms of--and 
part of our job is to look at some of the legal impediments for 
vulnerable populations: Gender violence, men having sex with 
men, commercial sex workers. What you would say should be some 
of your top priorities that we should consider?
    Ms. Akugizibwe. I think the issues that you have 
highlighted around vulnerable groups and the way that legal 
frameworks present the ability to access health services, such 
as sex workers, such as men who have sex with men, are some of 
the biggest challenges we are facing in the African region.
    Additionally, the introduction of laws that give punitive 
sanctions for what is called willful HIV transmission, which is 
often interpreted in many ways. For example, a woman who cannot 
negotiate safe sex with her husband and never had sex without a 
condom, but is HIV positive could then be prosecuted under 
these laws for willful transmission, and that has happened in 
several countries. I would be happy to provide you with more 
detail on some of the work that is highlighting these issues.
    I think another, much bigger challenge is also around the 
way that legal systems recognize other socioeconomic rights, 
such as nutrition, and it affects the success of HIV programs. 
And I think the failure by many countries to recognize basic 
socioeconomic rights is impacting our ability to successfully 
implement HIV programs, especially when it is compounded by the 
flatlining of budgets that we are seeing in many HIV programs 
as a result of global declines and funding. You have situations 
where people are willing to take treatment that is readily 
available, an anecdote I referred to earlier, but are not able 
to start it because they don't have food, because the HIV 
program, because of its reduced budget, has cut food packages 
out of the overall package of services, and the government 
hasn't stepped in to fill that gap.
    So those are the social challenges.
    Chairman Berman. The gentlelady has yielded back her time.
    All right. In that case I recognize for a couple of 
minutes--we do have to leave for vote--but for 3 minutes the 
gentlelady from Texas Ms. Sheila Jackson Lee.
    Ms. Jackson Lee. Thank you very much, Mr. Chairman, and I 
thank the witnesses.
    If I understand, the earlier testimony by Dr. Goosby and 
other--Ambassador Goosby, rather, and a number of the witnesses 
on the first panel was to affirm the importance of PEPFAR, 
Global Health Initiative. I want to affirm the importance of 
sustainability and to comment that when we have made progress, 
but still see sub-Sahara Africa with 67 percent of worldwide 
HIV infections and infections still occurring in 2008, it means 
that we still have work to do. And I would like to make our 
program focus itself more clearly on sustainability and a 
combined effort as I know we are with malaria and tuberculosis.
    So I would like to ask Ms. Akugizibwe, if I could, about 
the point that you just made about more funding and the lack of 
food packages, because at one time there was some dialogue that 
it was a nutrition issue. We know that we have dispelled that 
myth, but there is no doubt that you need to have nutrition, 
and you need to have a basis of healthiness, diet, so that you 
can continue to have people live longer if they are already 
HIV-infected.
    Would you just highlight and emphasize how we need to use 
our monies for sustainability in this fight against HIV/AIDS?
    Ms. Akugizibwe. I think, as I mentioned in my testimony, 
that sustainability, a key component of that is recognizing 
that investments now are beginning to pay off and will continue 
to do so at a greater scale if they are sustained. Although we 
are still seeing infections, we are also seeing for the first 
time a decline in the rate of new infections, especially in 
sub-Saharan Africa, and this is due in large part to the 
investment that has been made into treatment.
    And I can mention this investment in HIV programs and 
treatment has highlighted a lot of other social issues, such as 
gender violence, such as nutrition. And what is more 
interesting is that the HIV response and the civil society 
mobilization that just happened around that has been probably 
the most effective vehicle for mobilizing advocacy around our 
own Government's accountability in addressing these other 
challenges.
    So when we talk about government's investment in HIV 
treatment, it also gives us an opportunity to raise the 
investment in food and other----
    Ms. Jackson Lee. Can I ask Dr. El-Sadr to give a comment in 
my remaining short seconds? Can you just comment very quickly 
on that question, sustainability?
    Dr. El-Sadr. I think that we have had remarkable success, 
and I think, again--and it should be recognized even in the 
hardest hit countries. So the effect has been profound.
    There are investments today by the countries themselves in 
terms of the response to HIV/AIDS. So it is not a unilateral 
U.S.-supported response or largely from donors, but it is joint 
investment from the countries and from the external resources.
    The conversations that are happening within the countries 
now are to identify and recognize the national--the country 
contributions as well as the external investments.
    I think an investment today--what we need to do today will 
absolutely ensure the durability of this response and the 
ability to actually sustain it beyond the next 5 years. So 
stalling on the commitment today can have far-reaching impact 
on the ability to actually have a durable and sustainable 
response.
    Ms. Jackson Lee. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Berman. The time of the gentlelady has expired.
    You were great witnesses. Thank you very much for coming, 
and, without objection, the opening statement of the gentleman 
from New Jersey Mr. Payne will be included in the record.
    The committee is now adjourned. Thank you.
    [Whereupon, at 11:55 a.m., the committee was adjourned.]
                                     

                                     

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  Material submitted for the recrord by the Honorable Christopher H. 
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