    [Senate Hearing 114-143]
    [From the U.S. Government Publishing Office]

      STATE, FOREIGN OPERATIONS, AND RELATED PROGRAMS APPROPRIATIONS FOR
                                FISCAL YEAR 2016

                                  ----------

                             WEDNESDAY, MAY 6, 2015

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:12 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Lindsey Graham (chairman)
    presiding.
        Present: Senators Graham, Kirk, Lankford, Daines, Leahy,
    Shaheen, Coons, Merkley, and Murphy.

                              DEPARTMENT OF STATE

                             Global Health Programs

    STATEMENTS OF:
            DEBORAH L. BIRX, M.D., AMBASSADOR-AT-LARGE, COORDINATOR OF THE
                UNITED STATES GOVERNMENT ACTIVITIES TO COMBAT HIV/AIDS AND
                SPECIAL REPRESENTATIVE FOR GLOBAL HEALTH DIPLOMACY
            DR. MARK DYBUL, EXECUTIVE DIRECTOR, THE GLOBAL FUND TO FIGHT
                AIDS, TUBERCULOSIS AND MALARIA
            SIR ELTON JOHN, FOUNDER, ELTON JOHN AIDS FOUNDATION
            DR. RICK WARREN, PASTOR OF THE SADDLEBACK CHURCH

                  OPENING STATEMENT OF SENATOR LINDSEY GRAHAM

        Senator Graham. The subcommittee will come to order. Our
    hearing today is on global health programs, and we have a panel
    of incredibly brilliant people who I am honored to welcome to
    the United States Senate, so you inform the Senate, the
    American people, and the world about the good causes that you
    represent.
        Ambassador-at-Large Deborah Birx. Thank you very much for
    coming. Dr. Birx is the Coordinator of the United States
    Government Activities to Combat HIV/AIDS, and U.S. Special
    Representative for Global Health Diplomacy, U.S. Department of
    State.
        Dr. Mark Dybul, Executive Director of The Global Fund to
    Fight AIDS, Tuberculosis, and Malaria.
        Sir Elton John, Founder of the Elton John AIDS Foundation.
        Dr. Rick Warren, Pastor of Saddleback Church.
        To each of you, thank you for coming. You have incredible
    busy schedules and you made time to talk about causes near and
    dear to your heart.
        I will make a brief opening statement to the subcommittee
    members. Thank you for showing up. To Senator Leahy, it has
    been a pleasure working with you and Tim Rieser in the Minority
    and the Majority. As politics change in this country, Senator
    Leahy and I are going to make sure the commitment of this
    committee does not change.
        At the end of the day, I have tried along with Senator
    Leahy to shine a light on what foreign assistance does for the
    United States and the world. It is 1 percent of our budget, and
    here is what I would suggest to other members of the body: find
    an account anywhere throughout the budget that gets a better
    rate of return than the 150 International Affairs Budget
    Function account.
        One percent of the budget is about $50 billion when you add
    it all up. That includes all the funding for the State
    Department and our embassies, consulates, aid to Israel and
    other nations, and a small portion of it goes to fighting AIDS,
    malaria, tuberculosis, and other diseases.
        What I want the American taxpayer to know is that from my
    point of view, being a conservative Republican from South
    Carolina, I have never seen a better return on investment.
        The private sector, the Federal Government, and other
    international organizations and other governments have been
    collaborating for well over a decade to take the fight to AIDS,
    and we are winning and AIDS is losing.
        At the end of the day, the scourge is being put in a box,
    but growing in some areas of Africa for reasons that we must
    address.
        In terms of future commitment of money, now is not the time
    to back off. We are literally inside the 10 yard line when it
    comes to containing some of these diseases like AIDS and
    malaria, and there are thousands if not millions of young
    people alive today because of America's intervention and the
    taxpayers' generosity.
        It is a national security effort in my view to stabilize
    developing parts of the world so rampant diseases like AIDS,
    malaria, and tuberculosis can be contained, and does not create
    further instability in regions that are already unstable.
        From an economic point of view, we are creating a customer
    base where American companies one day can do business with
    millions of people on a continent that I have come to love that
    have an affinity for the American people and our way of life.
        America is at her best, I believe, when she is doing things
    that are right. Even though we have economic challenges here at
    home, compared to most, we are incredibly rich. Our richness is
    not in our bank account. I think it is in our attitude and the
    way the American people engage the world.
        If I had to give one example to someone from far away to
    explain America, I would use the 150 account. This account
    represents the best of the American people. It is transparent.
    It is well managed. It is saving lives and changing the world.
        Having said that, foreign assistance is at risk.
    Sequestration budget cuts if fully enacted will devastate the
    ability of this account and others to fulfill its promise. We
    are literally inside the 10 yard line, and the budget cuts that
    are coming under sequestration will destroy our ability to make
    progress, and we will lose many of the gains that we have
    achieved over time.
        When you are $18 trillion in debt, you need to evaluate
    your spending. Here is what I can say: the 150 account is not
    why we are in debt. This account makes us richer. This account,
    I believe, is the smartest use of Federal dollars of any place
    within the Federal Government, and it is my commitment working
    with my Democratic and Republican colleagues that we not
    abandon foreign assistance at a time we are so close to
    achieving the purposes of this account, which is to change the
    world in a positive fashion.
        With that, I will recognize Senator Leahy.

                     STATEMENT OF SENATOR PATRICK J. LEAHY

        Senator Leahy. Thank you, Mr. Chairman. You and I have
    worked together on this subcommittee for so many years. We go
    back and forth. Sometimes you are chairman, sometimes I am
    chairman. The thing is we come out with a bill almost always
    where we are in total agreement on it, and that is why it
    passes.
        This is an issue that should not be involved in partisan
    politics. I cannot think of programs we fund that has stronger
    support than global health. We support investments to combat
    diseases.
        I know last night in our discussions, Sir Elton and Pastor
    Warren, we talked about a lot of these diseases could be
    prevented, treated or cured for just a few dollars. If it
    happened to any one of us, we would come up with whatever
    amount of money it was. We are talking about countries where
    that money is not there.
        Very few Americans suffer from malaria, polio, Dengue
    fever, or river blindness. Can you imagine if they did? You
    would have people lined up out here saying what are you
    spending, let's do something about it.
        When you are in the wealthiest country on earth, we have
    some moral responsibilities. This goes beyond political or
    economics. If you have this kind of great wealth, you have some
    moral responsibilities, especially when these are diseases that
    affect millions of people, often children, in countries that
    have woefully inadequate health services.
        HIV/AIDS was identified 33 years ago. AIDS and tuberculosis
    continue to be a serious problem, not only worldwide, but here
    in the United States. We can do better, but the rates of
    infection here in this country pale compared to many other
    countries, Sub-Saharan Africa, Eastern Europe, Southeast Asia.
        The chairman has rightly pointed out the budget restraints
    we have, but that does not mean we suddenly have no money. We
    have a lot of money to spend as a country, and let's pick where
    we go. We just want to make sure we use our best resources.
        The Ebola catastrophe, that shows as vulnerable we are, as
    Bill Gates and others have warned this subcommittee. Ebola was
    a relatively easy disease to detect and contain before a person
    experiences symptoms. It is not a question whether such a virus
    will occur, but when and where, and if we do not invest
    relatively modest sums necessary to train and equip public
    health workers in countries where such a pandemic can
    originate, we are going to pay more than the hundreds of
    thousands and even millions of lives lost and dollars spent.
        These are things that Dr. Birx and Dr. Dybul certainly work
    on all the time.
        The chairman and I are supposed to also be in the Defense
    Appropriations and Judiciary, but we want to be here. You all
    have worked, every one of you, hard on these issues. Every one
    of you could find much easier things to tackle, and I applaud
    you all.
        Sir Elton, we have known each other for a number of years.
    You can sit back and just relax, instead you are out pushing us
    all the time. I do not want to say anything about Pastor Warren
    going after us on a moral issue, but the good Pastor has spoken
    to me about where our conscience should be on more than one
    occasion. That is important.
        Doctors, the expertise you bring, we need it. I will hush
    up. I would rather hear from these people. I am glad you are
    doing this, Mr. Chairman.
        Senator Graham. Thank you. Thank you for being a good
    partner here. Madam Ambassador, lead us off.

                      SUMMARY STATEMENT OF DEBORAH L. BIRX

        Ambassador Birx. Thank you, Chairman Graham and Ranking
    Member Leahy, and distinguished members of the subcommittee. I
    am honored to appear before you, specifically this subcommittee
    today, which has provided visionary leadership of the United
    States President's Emergency Plan for AIDS Relief (PEPFAR)
    since 2003.
        Millions of men, women, and children are alive today
    because of the compassion and bipartisan commitment of
    Congress, the leadership of President George W. Bush, and
    President Barack Obama, and the true generosity of the American
    people.
        As you have seen firsthand and as the chairman mentioned,
    PEPFAR is not only a transformative global health program, but
    is an outstanding expression of American diplomacy.
        I am privileged to be joined today by three great leaders
    in the global HIV/AIDS response, Ambassador Mark Dybul, whose
    incredible leadership of PEPFAR during a critical phase took
    the program to new heights, and whose work directing the Global
    Fund has been extraordinary. Pastor Rick Warren, a voice of
    compassion for those affected by the epidemic, and Sir Elton
    John, a powerful advocate for people living with HIV/AIDS for
    decades.
        PEPFAR has changed the very trajectory of the HIV/AIDS
    epidemic. At its core, PEPFAR has offered hope and healing, and
    the possibility of health and prosperity in the place of
    sickness, suffering, and death.
        Today because of PEPFAR, 7.7 million men, women, and
    children are receiving life saving treatment, and more than a
    million babies have been born HIV free. Six million five
    hundred thousand voluntary medical male circumcisions have been
    performed. Success as mentioned by the chairman is within our
    collective grasp, if we all focus, accelerate, and sustain our
    efforts.
        PEPFAR has deliberately strengthened all aspects of the
    health systems, not only those programs supporting people who
    live with HIV/AIDS, but programs around maternal and child
    health and global health security. Yet our work, as mentioned,
    is far from done.
        Every week, nearly 40,000 people are infected with HIV,
    7,000 of them young women. With the youth bulge in Sub-Saharan
    Africa, millions of young women are entering the window of the
    most susceptibility to HIV/AIDS infection. We have to work
    diligently right now to get and stay ahead of this epidemic.
        According to the Joint United Nations Programme on HIV/AIDS
    (UNAIDS), if we do not act now, there will be an estimated 28
    million new HIV infections by 2030, more infections than
    current resources can support. Actions taken over the next 5
    years will be critical. Coordinated efforts could reduce the
    number of HIV infections to under 200,000 per year by 2030, as
    compared to our current trajectory, which is unthinkable, of
    2.5 million new infections per year.
        PEPFAR is pivoting. We are utilizing a transparent data
    driven approach to target evidence based interventions to the
    highest burden populations and geographic areas for maximum
    impact of every U.S. dollar. Making this pivot is not an easy
    thing, but it is the right thing, and it will prevent new
    infections and lead to control of the epidemic.
        Earlier this year, we launched a sustainability index to
    provide an annual snapshot of the elements central to
    sustaining and controlling this epidemic, including the
    critical contributions partner countries are making towards
    their national response.
        PEPFAR leverages the expertise of the whole of the United
    States Government, civil society, faith based organizations,
    and other partners, including the private sector, to address
    the most glaring gaps in treatment and prevention.
        The Accelerating Children's HIV/AIDS Treatment Initiative
    or ACT, is a $200 million partnership with the Children's
    Investment Fund Foundation, to reach and treat 300,000
    additional children living with HIV/AIDS by the end of 2016.
        DREAMS, standing for Determined, Resilient, Empowered AIDS-
    free Mentored, and Safe Young Women, is a $210 million
    partnership with the Bill and Melinda Gates Foundation and the
    Nike Foundation to prevent HIV infection in adolescent girls
    and young women.
        Finally, we cannot control the epidemic without putting an
    end to the stigma and discrimination that forces people living
    with and at risk for HIV/AIDS to the very margins. All people
    need access to services, including key populations.
        At this critical time in the AIDS response, we know what
    needs to be done and we have the tools to do it. The continued
    leadership of the United States is vital to ensuring that we
    achieve an AIDS free generation, because the alternative is
    unthinkable.
        Chairman Graham, Ranking Member Leahy, members of the
    subcommittee, the unchartered terrain we are entering will test
    our resolve, but I am confident that we will reach our
    destination. The ways in which we are focusing, strengthening,
    and accelerating PEPFAR's efforts and partnerships will hasten
    our arrival.
        Thank you again for the opportunity to appear before you
    today. I am profoundly grateful for the ongoing and continuous
    unwavering support of this subcommittee for PEPFAR. I look
    forward to your questions.
        [The statement follows:]
                  Prepared Statement of Deborah L. Birx, M.D.
        Thank you Chairman Graham, Ranking Member Leahy, and distinguished
    members of the subcommittee. I am deeply honored to appear before your
    subcommittee, one which has provided visionary leadership and
    unwavering support for the U.S. President's Emergency Plan for AIDS
    Relief (PEPFAR) since its inception. Today, millions of men, women, and
    children are alive because of the compassion and commitment of the
    members of this subcommittee; the bipartisan, bicameral support of your
    congressional colleagues; the leadership of President George W. Bush
    and President Barack Obama; and the generosity of the American people.
    All Americans should be immensely proud of PEPFAR's achievements--
    because they are also their achievements.
        I am honored and humbled to be joined on this panel by three other
    great leaders in the global HIV/AIDS response. Ambassador Mark Dybul,
    whose incredible leadership of PEPFAR during a critical phase took the
    program to new heights, and whose work directing the Global Fund to
    Fight AIDS, Tuberculosis and Malaria (the Global Fund) has been
    extraordinary. Pastor Rick Warren, who has been a voice of compassion
    and a source of courage for those affected by the epidemic. And Sir
    Elton John, who has been a passionate and powerful advocate for people
    living with HIV/AIDS for decades--one whose unwavering personal
    commitment and charitable foundation have saved and improved so many
    lives.
        Over the past 12 years, with your extraordinary investment, PEPFAR
    has helped to transform the global landscape of HIV/AIDS and to halt
    the relentless escalation of new infections and climbing mortality
    rates. PEPFAR has provided life-saving HIV prevention, treatment, and
    care services; built and strengthened the capacity of country-specific
    and country-led responses in both government and civil society; and
    fostered collaboration among the U.S. Government, key global partners,
    and national governments around the world, as well as grassroots
    organizations, including many faith-based organizations, in some of the
    most remote locations. At its core, PEPFAR has offered hope and healing
    in place of sickness, suffering, and death.
        As of September 30, 2014, more than 7.7 million men, women, and
    children are receiving life-saving antiretroviral treatment (ART) with
    PEPFAR support. Over the past 2 years alone, PEPFAR has reached more
    than 1.5 million pregnant women living with HIV/AIDS with services to
    prevent mother-to-child transmission and improve maternal health. In
    total, more than 1 million babies have been born HIV-free. And PEPFAR
    has supported more than 6.5 million voluntary medical male circumcision
    procedures in Eastern and Southern Africa. Achieving an AIDS-free
    generation is no longer a distant dream, but a goal within reach if we
    focus, accelerate, and sustain our efforts.
                   the global hiv/aids epidemic then and now
        None of us who were there will ever forget what we witnessed just
    over a decade ago. The reports from those on the frontlines were
    fraught with despair. At that time, an HIV diagnosis was a virtual
    death sentence in many countries. The epidemic was devastating families
    and communities around the world with disastrous social and economic
    consequences. In the hardest hit regions of sub-Saharan Africa, infant
    mortality doubled, child mortality tripled, and life expectancy had
    dropped by 20 years or more. The rate of new HIV infections was
    exploding, and people were getting sick and dying during their most
    productive years, crippling economic growth and turning back hard-won
    gains in global health and development.
        Today, thanks in large part to PEPFAR and its many partners,
    together we have written a new chapter. Worldwide, new HIV infections
    have been halved from their peak in the 1990s and AIDS-related deaths
    have dropped by 35 percent since their apex in 2005. In the hardest-hit
    African countries, new HIV infections among children have declined by
    43 percent just since 2009. As of June 2014, more than 13.6 million
    people have access to life-saving ART globally. Only 50,000 in sub-
    Saharan Africa were receiving ART when PEPFAR began.
        In addition to providing millions of people with life-saving HIV
    prevention, treatment, and care services, PEPFAR has built health
    infrastructure and strengthened capacity through an emphasis on
    sustainability. These efforts have not only supported patients living
    with HIV/AIDS, but are also leveraged for maternal and child health,
    malaria, immunizations, and emergency disease outbreak response. We
    know that strong laboratories and well-trained laboratory specialists
    are critical to well-functioning health systems, enabling clinicians
    and health workers to diagnose and treat a range of diseases and
    conditions. Our investments in the integration of laboratory services,
    including laboratory networks, commodities, and the workforce have
    created a lasting infrastructure that positions partner countries to
    respond to a range of health challenges and threats.
        Our investments in human resources for health, including a new
    strategy released in 2015, support not only the education of healthcare
    professionals, but also task-shifting, innovative retention strategies,
    reemployment, and additional training of healthcare personnel. PEPFAR
    was proud to announce on the last World AIDS Day that by the end of
    fiscal year 2014, we have trained more than 140,000 healthcare workers
    to deliver HIV and other health services, exceeding the target set by
    Congress in PEPFAR's 2008 reauthorization.
        Despite this tremendous success, our work is far from done. If we
    continue on the current course, the global burden of disease will
    increase far beyond the global community's ability to respond--so we
    have to change the way we do business. Every week, nearly 40,000 people
    are newly infected with HIV globally. While HIV incidence has declined
    by two-thirds since its peak in sub-Saharan Africa, the population has
    increased by 340 million during the same period. And due to the ``youth
    bulge'' in sub-Saharan Africa, millions of young people are entering
    their most HIV susceptible years. In fact, 200 million people are
    between 15 and 24, giving Africa the youngest population in the world.
    It is estimated that the number of young people in Africa will double
    by 2045. Given these demographic trends, we have to work hard just to
    keep up with, and even harder to keep ahead of, the epidemic. It is
    clear that if we begin to drift, to lessen our aspirations, or fail to
    follow the science, we will have squandered our accumulated assets and
    allowed the accomplishments of the last decade to unravel, with
    enormous negative consequence to a great many young lives. To achieve
    epidemic control, we need to refocus our efforts, re-energize our
    partnerships, and reaffirm our commitments to accomplishing our goals.
               what it will take to control the hiv/aids epidemic
        Achieving epidemic control and, ultimately, an AIDS-free generation
    requires all partners to step up their efforts--PEPFAR, the Global
    Fund, partner countries, and others. No one entity can do this alone.
    It will take all partners, working in a focused, coordinated, and data-
    driven manner to succeed. That is why PEPFAR has prioritized key
    collaborations with multilateral organizations, including UNAIDS and
    the Global Fund.
        PEPFAR works closely with UNAIDS, drawing on the UNAIDS and partner
    country epidemiologic technical resources and capacity. UNAIDS is the
    international standard bearer in global HIV/AIDS for setting critical
    goals in the global call to end the epidemic. Our collaboration with
    UNAIDS supports countries in overcoming key policy, programming, and
    implementation challenges. PEPFAR works with the Global Fund to
    maximize our joint investments. Increased partnership between PEPFAR
    and the Global Fund serves to improve the impact of our investments
    through more strategic use of resources and of our programs through
    better, more efficient, and evidence-based use of funds; technical and
    programmatic equality to maximize outcomes; and collaboration to
    promote country-level sustainable solutions.
        According to the Joint United Nations Programme on HIV/AIDS
    (UNAIDS), if we do not act now, there will be an estimated 28 million
    new HIV infections by 2030--far more than current resources can
    support. To accelerate progress toward averting new infections and
    turning the tide on the HIV/AIDS epidemic, UNAIDS has announced an
    ambitious 90-90-90 global treatment target--90 percent of people with
    HIV diagnosed, 90 percent of those diagnosed on ART, and 90 percent of
    people on treatment virally suppressed by 2020. UNAIDS' analysis shows
    that it is possible to control the HIV/AIDS epidemic, but actions taken
    over the next 5 years are particularly critical. UNAIDS estimates that
    aggressive coordinated efforts by donors and national health and
    finance ministries aimed at a ``Fast-Track'' strategy to confront the
    disease could reduce new infections to as few as 200,000 per year by
    2030, as compared with 2.5 million per year if existing policies are
    maintained. The financial costs of the failure to change course are
    clear: 2.5 million new infections each year will cost an estimated $2
    billion annually just to provide services to people living with HIV/
    AIDS.
        Reaching the 90-90-90 treatment target requires expanding access to
    HIV prevention, treatment, and care services. It also means shifting
    the way we all do business. In recent years, international donor HIV/
    AIDS funding has plateaued. In 2013, domestic investments from low- and
    middle-income countries accounted for approximately half of all HIV/
    AIDS-related spending. Even with this remarkable increase, there is
    insufficient financing to meet all the needs. To get ahead of the
    epidemic, we must target our efforts, accelerate investments in
    prevention and treatment, and increase the impact and effectiveness of
    every dollar spent. And access to viral load testing will be essential
    to ensuring that those living with HIV/AIDS know their treatment has
    been effective. That is why PEPFAR is pivoting to support evidence-
    based interventions in the highest-burden populations and geographic
    areas for maximum impact.
        Making this pivot is not the easiest or most popular thing, but it
    is the right thing and the smart thing--because it will prevent new
    infections. The PEPFAR program has the unique flexibility to make this
    critical shift, informed by the granular-level data available to us.
    Each new infection averted saves lives and saves money--today and in
    the future. For every 1,000 patient-years of treatment--for example,
    having 500 people on treatment for 2 years, 226 patient deaths are
    averted, 432 children are not orphaned, and 99 new infections are
    averted. To achieve epidemic control and, ultimately an AIDS-free
    generation, these efforts will need to be complemented by similar
    program shifts by the Global Fund, partner countries, and other donors
    as well as new investments.
        Each new HIV infection adds to the cost of controlling the disease.
    Without new investments and greater program efficiency, the cost will
    become unsustainable. Countries taking on a greater share of the
    response is a difficult but necessary fiscal and financial management
    challenge. That is why PEPFAR and the U.S. Department of Treasury are
    exploring collaboration with partner country Finance Ministries, with
    the goal of working in partnership with the World Bank, the
    International Monetary Fund, and other international financial
    institutions to help prepare public budgets to assume a greater share
    of the costs for HIV/AIDS programs, and to provide technical assistance
    to build state capacity in public financial management.
        PEPFAR has always been committed to treating people living with HIV
    before they develop full-blown AIDS. This priority also has direct and
    indirect economic benefits. Healthy people are able to work and support
    their families. Keeping parents healthy also lessens other social
    costs, such as caring for orphans whose parents die of AIDS-related
    illnesses. It has been shown that the economic benefits of treatment
    will substantially offset, and likely exceed, program costs within just
    10 years of investment. In other words, treating people will not only
    save lives but will also generate considerable economic returns.
        Controlling the HIV/AIDS epidemic also requires a social, policy,
    and legal environment that encourages and enables people to access and
    use core HIV/AIDS services. The principles of good public health
    necessitate that we work to eliminate barriers to these services for
    all people--including key populations. PEPFAR is committed to ensuring
    that partners receiving PEPFAR funds implement their programs in a way
    that supports promotion, protection, and respect for human rights,
    including for lesbian, gay, bisexual, and transgender people. We are
    building the capacity of civil society organizations, engaging partner
    governments, and working in concert with our multilateral and bilateral
    partners. Our public-private partnerships are central to this effort as
    well. PEPFAR and the Elton John AIDS Foundation launched a $7 million
    public-private partnership to expand access to non-discriminatory HIV-
    related services for men who have sex with men and transgender
    individuals, with an initial focus on South Africa. These principles
    also demand that we deliver HIV/AIDS services even when facing
    difficult cultural contexts, severe stigma and discrimination, or
    challenging security environments. This fundamental commitment has
    underpinned PEPFAR from the beginning, and we will never waver from it.
                  changing the way we do business for results
        Over the past 12 years, PEPFAR has evolved from an emergency
    program to one focused on achieving sustained epidemic control. In my
    first year as the U.S. Global AIDS Coordinator, we have worked hard to
    transform the way that PEPFAR does business to maximize the impact of
    every dollar with which we are entrusted by Congress and American
    taxpayers.
        Within the U.S. Government efforts, we have seen incredible
    leadership at the Department of State, including the important
    contributions of Chiefs of Mission, as well as the dedicated staff
    working for PEPFAR's implementing agencies: the Department of Defense;
    Department of Health and Human Services and its agencies, including the
    Centers for Disease Control and Prevention, the Food and Drug
    Administration, the Health Resources and Services Administration, the
    Substance Abuse and Mental Health Services Administration, and the
    National Institutes of Health; the Department of Labor; the Peace
    Corps; and the United States Agency for International Development.
        We released ``PEPFAR 3.0--Controlling the Epidemic: Delivering on
    the Promise of an AIDS-free Generation,'' which outlines how PEPFAR
    will help to control the epidemic by focusing on doing the right
    things, in the rights places, right now--through five core action
    agendas:
      --Impact Action Agenda: focusing resources and leveraging finances to
            address the most vulnerable populations and to control the
            epidemic.
      --Efficiency Action Agenda: increasing transparency, oversight, and
            accountability across PEPFAR and its interagency partners to
            ensure every taxpayer dollar is optimally invested and tracked.
      --Sustainability Action Agenda: ensuring that when the U.S. and
            partner countries have scaled up interventions and reached
            epidemic control, the services, systems, financing, and
            policies required to maintain that control are readily
            available to PEPFAR beneficiaries.
      --Partnership Action Agenda: strengthening partnerships, including
            with the Global Fund, to achieve sustainability and ultimately,
            an AIDS-free generation.
      --Human Rights Action Agenda: securing, protecting, and promoting
            human rights and addressing the human rights challenges of
            those affected by the disease.
        We have moved swiftly to help tackle two of the most glaring gaps
    in the response--the distressing disparity in HIV/AIDS treatment for
    children; and the alarming rates of new HIV infections among adolescent
    girls and young women.
        In 2013, 3.2 million children under the age of 15 were living with
    HIV/AIDS globally--more than 90 percent in sub-Saharan Africa.
    Tragically, only 24 percent have access to ART. Children living with
    HIV/AIDS are one-third less likely to receive treatment compared to
    adults. Without treatment, half of the children infected with HIV at
    birth or in infancy will die before their second birthday, and 80
    percent will die before their fifth birthday. That is why, last August,
    PEPFAR launched the Accelerating Children's HIV/AIDS Treatment (ACT)
    Initiative--an ambitious $200 million partnership with the Children's
    Investment Fund Foundation to reach 300,000 more children living with
    HIV/AIDS with treatment by the end of 2016.
        Every year, an astonishing 380,000 adolescent girls and young women
    are infected with HIV, 7,000 every week, over 1,000 every day. And in
    2013, nearly 60 percent of all new HIV infections among people aged 15-
    24 occurred among adolescent girls and young women. That is why, last
    World AIDS Day PEPFAR joined with the Bill & Melinda Gates Foundation
    and the Nike Foundation to launch the $210 million DREAMS Partnership
    to ensure that adolescent girls and young women have an opportunity to
    live Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe
    lives.
        These and other impactful public-private partnerships are allowing
    PEPFAR to leverage the expertise, assets, and experience of the private
    sector--maximizing the U.S. Government's investment in addressing these
    and other urgent needs. In 2014 alone, private sector partners
    contributed $264 million to increase the scale and impact of PEPFAR's
    work. Civil society organizations and faith-based organizations (FBOs)
    have been critical PEPFAR partners from the outset, and played a
    pivotal role in the HIV/AIDS response since the earliest days of the
    epidemic. Time after time, civil society has sounded the alarm,
    demanded accountability and transparency, delivered life-saving
    services, and driven transformational change in communities and
    countries. Historically, FBOs have provided an estimated 30-70 percent
    of healthcare services in sub-Saharan Africa. In Kenya, faith-based
    health facilities operated by diverse religious traditions are
    essential health providers for low-income households--accounting for 70
    percent of the not-for-profit, non-governmental health facilities in
    the country. Two-thirds of faith-based health facilities in Kenya's
    high-incidence counties provide some type of HIV/AIDS service. And in
    Nairobi, the county with the largest number of people living with HIV/
    AIDS in Kenya, FBOs provide more than 60 percent of antiretroviral
    medications.
           using and sharing data for greater transparency and impact
        Just as harnessing existing partners and enlisting new ones is
    vital to our success, so are using and sharing data. PEPFAR is doing
    this in unprecedented ways, and we are just getting started. We have
    been steadfast in the adoption of a data-driven, targeted approach to
    address one of the most complex global health issues in modern history.
    We use an implementation science model--a scientific framework--to
    guide program implementation and scale-up that focuses on effectiveness
    and efficiency in order to continually build the evidence base
    necessary to inform the best approaches to achieve high-impact,
    sustainable prevention, care, and treatment programs. We are examining
    data down to the most granular site level to strategically target
    geographic areas and populations with the highest HIV/AIDS burden to
    achieve the greatest impact for our investments. As part of PEPFAR's
    Efficiency Action Agenda, our Expenditure Analysis Initiative ensures
    that PEPFAR expenditures can be analyzed by program area, cost category
    and country, including sub-national geographic units. The analysis
    links routinely collected results data with expenditures to calculate a
    PEPFAR unit-expenditure per achievement. Expenditure Analysis
    facilitates joint planning with country governments and other donors
    ensuring improved coordination of resources in support of national
    treatment goals and comprehensive HIV programming. PEPFAR will continue
    to lead the global community in these efficiency initiatives and will
    expand the use of key tools for analysis and other innovations in order
    to save even more lives.
        And because data are only useful when they are accessible,
    understandable, and actionable, PEPFAR is opening its data to drive
    program efficiency, transparency, coordination, and mutual
    accountability. This includes posting on our Web site the first-ever
    PEPFAR Dashboards, enabling all to view, download, and utilize PEPFAR
    data. We have also launched a new 3-year, $21.8 million partnership
    with the Millennium Challenge Corporation to support country-led open
    data systems in a number of countries.
        PEPFAR is also deeply committed to demonstrating and improving the
    impact of the American people's investments. One way we do so is by
    conducting national HIV/AIDS Impact Assessments (HIA). HIA collect data
    on HIV prevalence, incidence, historic mortality, and service coverage
    down to the household level, providing direct evidence of how well an
    epidemic is transitioning in a country. By the end of next year, PEPFAR
    will have supported implementation of new HIA in 17 countries, wherever
    possible inclusive of viral load monitoring.
        The data that drives and informs PEPFAR's work are a key component
    of our Sustainability Action Agenda, where the U.S. Government aims to
    engage partner governments and civil society in service and systems
    strengthening. In 2015, PEPFAR launched a Sustainability Index, which
    provides an annual snapshot of the state of the elements central to a
    sustained and controlled epidemic. The use of this index will allow
    PEPFAR to objectively track progress toward sustainability goals. These
    goals are country-led and have been supported by PEPFAR in order for
    countries to increase capacity for domestic service delivery, finance,
    and strategic investment; accountability and transparency, including
    civil society engagement. While financial sustainability is just one
    element of our index, it is worth noting that a number of countries
    have increased their domestic financing for HIV/AIDS. For example,
    Botswana funds 90 percent of its treatment response; South Africa
    invests over $1.6 billion annually, comprising nearly 80 percent of the
    HIV/AIDS response in the country; Namibia finances nearly two-thirds of
    the national HIV/AIDS response with domestic resources; and Zambia has
    made significant domestic investments as well. PEPFAR is actively
    working with partner countries to further expand their investment in
    health.
                                 the road ahead
        Chairman Graham, Ranking Member Leahy, distinguished members of the
    subcommittee, the road ahead will be challenging, it will test our
    resolve; however, I am confident that we will reach our destination.
    The ways in which we are focusing, strengthening, and accelerating
    PEPFAR's efforts and partnerships will hasten our arrival. As the
    members of this subcommittee have witnessed firsthand over many years,
    PEPFAR is not only a transformative global health program, but it is
    also an outstanding expression of American diplomacy reflecting the
    enduring compassion of the American people.
        Over the last 12 years, PEPFAR has adapted, responding to changing
    needs on the ground among the people we serve. We have taken lessons
    learned to heart and our stewardship over PEPFAR has been informed by
    our clear responsibility to spend each dollar appropriated to us by the
    U.S. Congress and the American people in the most wise and purposeful
    way. We cannot afford not to. Our work is guided each day by the memory
    of the nearly 40 million people who have died since the HIV/AIDS
    epidemic was first recognized, including the estimated 1.6 million
    lives lost in this past year. We are inspired by the millions of people
    who are living with HIV/AIDS today to work harder, faster, and smarter
    with our partners across the globe to achieve an AIDS-free generation.
    And it is possible if we remain focused, steadfast, and keep pushing
    forward together.
        Mr. Chairman, thank you for the opportunity to appear before you
    today. We are profoundly grateful for the ongoing support and
    engagement of your subcommittee for PEPFAR's work. I look forward to
    your questions.

        Senator Graham. Thank you very much. I would like to
    mention that Bono could not be here today. He wanted to be. He
    had a very difficult accident. He is doing better. I just want
    to recognize his contribution to this cause.
        Bono communicated with me several times regretting not
    being able to be here, but ONE is one of the anchor tenants of
    this whole effort worldwide. I just want to recognize the fact
    that he is with us in spirit.
        Senator Leahy. Could I just interject? He has also kept his
    good sense of humor. When I called him after his accident, he
    was back in Dublin. He said, well, the fellow members of the
    band said it was a good thing he was wearing his helmet so he
    did not damage the sidewalks of New York.
        Senator Graham. Friends like that. Mark.

                      SUMMARY STATEMENT OF DR. MARK DYBUL

        Dr. Dybul. Thank you very much, Mr. Chairman. Chairman
    Graham, Ranking Member Leahy, members of this distinguished
    subcommittee and your expert staff, thank you for your
    leadership.
        This subcommittee, this chamber, this Congress and two
    administrations have reached across party lines to reach those
    in need. Your compassion and insight reflect the best of the
    American people.
        You have changed the landscape from working on death to
    being on the brink of ending three plagues, two that have been
    around since recorded medical history, and the modern Black
    Death, HIV/AIDS, while building resilient health systems,
    resilient societies, and resilient economies.
        Thanks also for including me on this panel. It is a little
    humbling to be here with a world famous preacher, a world
    famous performer, and an expert scientist, but all friends for
    many years. I will try to do my best to make three points.
        With your leadership, continued leadership, we can make
    history, strengthen partnership through shared responsibility,
    and drive innovation. Advances in science, which I know you
    have heard about before, and also the experience of the
    investment you have made over the last 15 years, have put us on
    the brink of ending malaria and tuberculosis, again, that have
    been around since recorded medical history, and HIV/AIDS, on
    the path to not be epidemics any more, to end them as public
    health threats.
        With your leadership, the curves of these new infections
    have dropped dramatically. For example, 55 countries are on the
    path to reduce malaria by 75 percent by the end of next year,
    and 26 of them are on the path to elimination.
        There has been remarkable progress in reducing deaths. But
    as Ambassador Birx pointed out, we now have a clear choice to
    work toward the goal of ending these epidemics or we can risk
    the resurgence of these diseases undermining your investments
    of the last 15 years.
        The Global Fund has contributed to this progress. We have
    raised about $4 billion a year, in large part thanks to your
    generosity, and have contributed to putting 7.3 million people
    on antiretroviral treatment, 12 million have been tested and
    effectively treated for tuberculosis, and 450 million bed nets
    have been distributed.
        The Global Fund is the largest funder of TB and malaria
    external financing, so these efforts are incredibly important.
        As Chairman Graham pointed out, beyond the health of
    individuals, these diseases have enormous impact on economic
    loss in the developing world. For example, it is estimated that
    Nigeria alone loses $3.5 billion per year in its GDP because of
    malaria.
        The reality is healthy productive people make healthy
    productive nations and good trading partners. It is therefore
    not just an issue of public health but also of economic
    interest to accelerate our progress towards ending these
    diseases.
        As you all have pointed out, by working together we can
    also bring out the best in humanity. Collective commitment can
    change the course of history by ending these epidemics while
    lifting up human beings, that are often left behind and
    marginalized.
        Ambassador Birx mentioned young women. Young women are
    often 5 to 10 times more likely to be infected than young boys,
    5 to 10 times more likely. They are driving the epidemic. With
    the youth bulge, the increase in young people, there is a risk
    of an explosion undermining the progress that has been made.
        New data suggests that if we can work just to support and
    keep girls in school, HIV rates can drop by 60 percent. If
    those girls stay in school, they also do not get married early,
    do not get pregnant early, have economic opportunity, and they
    will reinvest in health education, nutrition, and bringing
    opportunities to their children.
        We are working closely with the DREAMS Initiative, PEPFAR,
    USAID, the Gates Foundation, and others to intervene here to
    fundamentally change the course of these girls' history.
        Investments in HIV, TB, and malaria over the past decade
    are bringing a broadened positive effect on the rural health
    systems as well, including in response to Ebola. I was recently
    in Cote d'Ivoire and Senegal, and it was women who were trained
    to go door to door on malaria that were actually going to door
    to door to prevent and fight Ebola.
        How do we achieve the goals of ending epidemics and
    building resilient health systems and societies? We do it
    through partnership. The Global Fund is probably the world's
    largest public/private partnership.
        We are actually the public/private partnership arm of the
    U.S. Government's response to these diseases, and we work
    closely with Ambassador Birx's PEPFAR, the President's Malaria
    Initiative, USAID, and others.
        For every dollar the U.S. contributes to The Global Fund,
    we leverage $2 from over 25 countries, the European Commission,
    private foundations, corporations, and the faith community.
        As part of the Fund's new approach to financing, we are
    requiring countries to match what we invest in, what you invest
    in, to unlock the resources. So far, we have leveraged $3.9
    billion in the past 2 years in order to increase countries' own
    contributions to fighting their epidemics.
        As we know, based on USAID reports, countries are now
    investing more in HIV than the external financing, which is
    pretty remarkable. It has been happening since 2012. They have
    long provided 80 percent of the financing for tuberculosis and
    more for malaria.
        This increase in country contribution is critical, but the
    private sector is as well. The Global Fund has had $1.7 billion
    contributed to it from the private sector, while Bill and
    Melinda Gates have been the largest contributors, Bono, through
    Product Red, something he created, and its corporate partners
    have contributed over $300 million.
        We are also accessing high net worth individuals from
    countries like India, Indonesia, South Africa, and Vietnam. We
    have commitments for over $100 million from these individuals,
    and we are working to get more.
        The faith community has done a remarkable job both as
    implementers, where we fund 73 percent of them, but also as
    funders. Bishop Bickerton of the United Methodist Church handed
    over a check for $9 million last week here on the Hill.
        Rick Warren and his group have done a remarkable job
    advancing the fight against the disease. People like Elton John
    get deep into the community to ensure that people are not left
    behind.
        The private sector not only gives money, they also partner
    with us to do things. Coca-Cola is working with us to ensure
    distribution. Who better to work with on distribution of drugs
    and commodities.
        We are reducing the price of commodities. In 2 years
    through an initiative that we have launched we saved $500
    million by better negotiations. Now, that is value for money.
        Mr. Chairman, Ranking Member Leahy, and distinguished
    members, you are the leaders that will make this happen. Thank
    you for your support, and we look forward to continuing to
    working with you and serving you as your public/private
    partnership arm to fight these diseases.
        [The statement follows:]
                      Prepared Statement of Dr. Mark Dybul
        Chairman Graham, Ranking Member Leahy, and members of the
    subcommittee:

        It is humbling to be before this distinguished subcommittee with a
    remarkable panel of friends and colleagues of many years. Thank you
    very much for your strong, bipartisan leadership on global health and
    development. The consistent support of this entire subcommittee, has
    been remarkable. I would also like to acknowledge the close bicameral
    work with your colleagues in the House of Representatives, Chairwoman
    Kay Granger, Ranking Member Nita Lowey and all of the members of their
    subcommittee. It is a fantastic example of Congress working together to
    support critical global health and development programs and American
    interests abroad. I am amazed at the significant work being done around
    the world with such a small fraction of the U.S. Federal budget.
        This Chamber and subcommittee has been a driving force in global
    health and development. Senators Frist and Kerry designed some of the
    early legislation that formed the basis for the President's Emergency
    Plan For AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS,
    Tuberculosis and Malaria (the Global Fund). Then Senator Obama co-
    sponsored the reauthorization of those programs in 2008, and has
    remained a strong supporter of them, continuing what was begun by
    President Bush.
        By funding global health programs on preventable diseases, your
    leadership, and through you, the leadership of the American people, has
    significantly contributed to preventing many millions of new infections
    and saving millions of lives. You have catalyzed the development of
    sustainable and resilient health systems in many countries, and
    supported healthier, more productive stable families, communities and
    nations generating lasting impact on the world at a scale that is
    difficult to fully appreciate. And you have enhanced the view of the
    United States and the American people in countries you have supported.
    People know what the American people stand for when you stand with them
    through difficult times.
        We now have the opportunity to make an even bigger difference and
    impact: we can further drive down the rates of mortality and increase
    years of productive lives by ending the biggest communicable diseases
    of our time.
        We will only be successful with a partnership approach that allows
    countries with a high burden of disease to be in the lead. The Global
    Fund is a 21st-century partnership that is designed to accelerate the
    end of AIDS, tuberculosis and malaria as epidemics. The partnership
    includes governments, civil society, the private sector, the faith
    community and those affected by HIV, TB and malaria. By raising and
    investing nearly $4 billion a year tremendous results have been
    achieved to date: 7.3 million people are on antiretroviral therapy,
    12.3 million have been tested and treated for tuberculosis, and 450
    million mosquito nets have been distributed to protect children and
    families from malaria. Today, with your leadership and able U.S.
    Government leadership of PEPFAR by Ambassador Deborah Birx and the
    President's Malaria Initiative (PMI) by Admiral Timothy Ziemer, we are
    making advances in global health that we could not have dreamed a
    little more than a decade ago.
        I would like to highlight 3 important topics:
      --Creating opportunity for millions and building resilient health
            systems;
      --Evolving the partnership through shared responsibility catalyzed by
            U.S. leadership; and
      --Driving innovation to bring new solutions, ideas and partners to
            the fight against AIDS, TB and malaria.
      1. now is the time--creating opportunity for millions and building
                            resilient health systems
    An historic moment in global health and development
        New scientific advances and growing experience in implementation
    now make it possible to eliminate HIV, TB and malaria as threats to
    public health, by ending them as epidemics. Your are the first
    generation of leaders with the opportunity to end two plagues--malaria
    and tuberculosis--that have been with us since recorded medical
    history, and the modern Black Death--HIV/AIDS.
        With your strong support, the curves of new infections in HIV, TB
    and malaria are being bent in a downward direction and there has been a
    significant reduction in deaths. Your investments have not only
    improved health but have proved to be an essential component of gains
    related to education, the reduction of inequalities and economic
    growth. We now face a clear choice: we can accelerate our work toward
    the goal of ending these epidemics, or we can maintain current
    commitments and risk a resurgence of infectious diseases and
    undermining of the last decade of investments in global health.
        In addition to affecting the health of individuals directly,
    infectious diseases are having an impact on whole societies, economies
    and political systems. In the developing world in particular, crucial
    sectors for sustained development such as health and education, have
    seen a marked loss of qualified personnel, as a result of the three
    diseases. These and other infectious agents not only take an enormous
    physical toll on humanity, but also cause significant economic losses
    both directly in the developing world and less directly in the
    developed world. For example, it is estimated that Nigeria alone loses
    $3.5 billion per year in GDP due to malaria. Healthy, productive people
    make healthy, productive nations--and good trading partners. It is
    therefore a matter not only of public health, but also of economic
    interest, to accelerate progress in ending the diseases.
        By working together, we can also bring out the best in humanity, by
    recognizing every individual as an equal participant in building
    healthy societies, where opportunity is extended to all. Collective
    commitment can change the course of history by achieving an end to
    these epidemics. For example, in Southern Africa, the rate of HIV
    infections in young women can be 5 to 10 times the rate in young men.
    Sexual assault and abuse--gender inequality--is driving HIV infections.
    Because of the ``youth bulge''--a significant increase in the number of
    young people--without rapid action, rather than driving towards the end
    of the HIV epidemic, we could see an explosion of new infections. We
    have known that girls and young women, and boys, in school have a much
    lower rate of infection than those out of school. Recent data
    demonstrate that providing relatively small incentives to keep young
    women in school can reduce the rate of HIV by 25 to 60 percent. And
    adolescent girls that have good health and education are far less
    likely to become child brides and to become pregnant early. And they
    are far more likely to become women with economic opportunity who will
    spend 92 cents of every dollar they earn to feed, educate and provide
    healthcare to their children creating a virtuous cycle of equal
    opportunity, health and economic growth. We are working closely with
    PEPFAR's DREAMS initiative and USAID, the World Bank, the Gates
    Foundation and others to support countries to fundamentally change the
    course of their history.
        But we now have the knowledge to end HIV, TB and malaria as
    epidemics, strengthening economies and creating an inclusive human
    family. With your leadership, together we can make history.
    Building resilient health systems
        Investments in HIV, TB, and malaria over the past decade are having
    a broad and positive effect on the overall health system, as evidenced
    by decreased incidence and deaths in numerous African countries. An
    unfortunate illustration of the gap in the ability of the health system
    to conduct surveillance and rapidly responding to infectious disease
    threats was seen during the recent Ebola outbreak in three post-
    conflict environments in which all systems, including health, were
    greatly weakened. However, not enough attention has been focused on the
    countries that did control the epidemic, or prevented it from starting
    in the first place. Investments in community health workers and the
    basics of health systems made a difference. I was recently in Cote
    d'Ivoire and Senegal and was in Mali during the early stages of its
    outbreak. The health workers trained and deployed for so called
    disease-specific responses made a difference. In a village in rural
    Senegal, I met the woman who goes door to door to deliver malaria
    bednets, to make sure they are used and who checks every person with a
    fever for malaria, who led the effort against Ebola.
        More than one third of the Global Fund's investments go to
    strengthening health systems in the countries and communities where
    programs treat, prevent and care for those affected by the three
    diseases. A strong data system is critical to detect emerging issues
    and manage care for patients, as the Ebola outbreak has demonstrated.
    Investments in improving the efficiency of in-country supply chains are
    also critically important to improving health systems and a key
    priority of the Global Fund due to our large investments in
    commodities.
        As a means of responding to the health, humanitarian, and
    development crisis in West Africa due to the Ebola virus, the Global
    Fund continues to support Sierra Leone, Liberia and Guinea in their
    efforts to re-build their health systems.
    2. evolving the partnership through shared responsibility catalyzed by
                                u.s. leadership
    A two-to-one return on investment
        The Global Fund's public-private partnership model has achieved
    significant results for global health, and one of the main reasons is
    its ability to leverage investment, notably from the United States as
    its largest donor. For every $1 the United States contributes to the
    Global Fund, other countries and the private sector contributes $2. Not
    only does this greatly increase resources ensuring that the fight
    against the diseases is not born by the United States alone, it
    magnifies impact. With the Global Fund currently responsible for
    approximately 22 percent of international financing for HIV/AIDS (with
    over 50 percent of Global Fund resources dedicated to HIV/AIDS), more
    than half of international financing for malaria, and 72 percent of
    international financing for TB, these investments are essential to
    ending these epidemics.
        For the more than $12 billion that Global Fund will invest between
    2014 and 2016, the United States is on track to provide at least $4
    billion. This fulfills the pledge President Obama made when the United
    States successfully hosted the Global Fund Replenishment launch here in
    Washington, DC. in 2013. Support for the Global Fund comes from over 25
    countries, the European Commission, private foundations, corporations
    and faith-based organizations.
    Catalyzing new donors and increased domestic contributions
        Despite the strong support from traditional donors, it is clear
    that reliance on external sources is not sustainable. To make a truly
    transformational difference in the lives of millions of people affected
    by the three diseases, increased efforts are needed to mobilize
    resources from both new donors, and importantly, domestic resources.
    Increased domestic funding for health means greater country ownership
    and sustainability, which will ultimately translate into more impact,
    lives saved, and greater economic growth.
        As a part of a new approach to financing, in 2014 the Global Fund
    developed a Domestic Financing for Health Strategy and introduced a
    requirement that countries match 15 percent of every grant with an
    increase in domestic resources for health. Thus far, this has generated
    approximately 51 percent in additional domestic funding for the 2014 to
    2016 period, accounting for nearly $3.9 billion in additional funding
    from 110 countries for sustainable health gains. Because of collective
    efforts, UNAIDS reports that since 2012 domestic resources have
    outpaced external funding for HIV/AIDS. That has long been the case for
    tuberculosis where implementing countries fund 80 percent of their
    programs and domestic investments in malaria are lower but growing. The
    U.S. Government is also very actively engaged in increasing domestic
    funding, and this is another area where we are working closely
    together.
        Further expanding the Global Fund partnership to engage new powers
    and emerging economies is a priority. China, Korea, Thailand, South
    Africa, Nigeria and Namibia already contribute to the Global Fund.
    Emerging economies can play an increasing role in global heath through
    co-investment opportunities, the leveraging of domestic private sector
    investments and promotion of innovative finance mechanisms.
    The private sector
        A strong and growing partner for the Global Fund has been the
    private sector. Through direct contributions, the private sector has
    invested $1.7 billion to date. Bill Gates, who recently testified to
    this subcommittee, has been the largest single private sector
    contributor through the Bill and Melinda Gates Foundation and is a
    strong ally in engaging new contributors to the Global Fund.
        Private corporations' and high net worth individuals' donations to
    the Global Fund have increased by more than 50 percent since 2010.
    Since the Global Fund Replenishment meeting in Washington, DC in 2013,
    an additional $42 million in private sector pledges have been raised,
    including new pledges from MAC AIDS Fund, Goodbye Malaria and Comic
    Relief. PRODUCT (RED), created by Bono and Bobby Shriver, and its
    corporate partners increased their pledge by $30 million dollars
    bringing the total contributed by (RED) to nearly $300 million.
        With the support and leadership of Bill Gates, high-net-worth
    individuals from India, Indonesia, South Africa and Vietnam have also
    made commitments to the Global Fund of more than $100 million.
        Equally exciting are the innovative financing mechanisms being used
    to channel such resources. In Indonesia, a private sector health fund
    is being established to complement government investments. These
    private sector driven health funds have several key advantages: they
    bring new domestic resources to health; because the funders are
    business leaders, they have significant influence and can push for
    increased government financing for health that they can agree to
    ``match'' with private sector contributions, and; they can drive
    greater efficiencies and value for money by bringing good business
    practice to government efforts.
        Therefore, the private sector contributes much more than money--
    they contribute new solutions, ideas and innovation to global health
    and development. This topic will be discussed in greater detail in the
    section on Innovation.
    The faith-based community
        Similarly, we continue to work hand-in-hand with faith-based
    organizations, which are critical to every stage of Global Fund
    operations. Globally, faith based organizations have received over $900
    million in grants as Global Fund sub-recipients, funding projects in at
    least 73 countries. Just last month here in the Capitol, Bishop
    Bickerton of the United Methodist Church announced an extraordinary
    $9.6 million contribution. Combined with their previous donation of
    $8.5 million, the United Methodist Church's total contribution of $18.1
    million to the Global Fund is unprecedented.
        But the faith-based community offers far more than money. It is a
    great pleasure to be here with my dear friend Pastor Rick Warren. The
    PEACE Plan initiated by Rick and Kay's Saddleback Church is a great
    example of what happens across the United States when churches,
    synagogues and mosques act from their belief that we are all sisters
    and brothers as children of the author of life, and ``to whom much is
    given, much is required''. The faith community does not prevent or
    treat diseases, they care for a whole person worthy of respect and
    love. Saddleback performs its great works of mercy through their own
    resources, and we are privileged to work with them and to support
    faith-based organizations around the world.
        Beyond its partnership with the United Methodist Church, the Global
    Fund is further strengthening its ties with faith-based organizations
    and encouraging governments to directly finance faith-based
    organizations. This will enable health programs to reach deep into
    communities to support effective prevention, care and treatment
    programs. I have delivered this message of the importance of faith-
    based organizations and community systems to heads of state and
    government in countries I have visited. The linkages between
    governments, faith-based organizations, non-governmental organizations
    (NGOs) and communities are becoming all the more important as domestic
    financing for health increases.
    Community-based organizations
        Among the reasons the faith community is so effective is that they
    meet people where they are--they are not only in the community, they
    are of the community. Similarly, other community-based organization,
    including those of the people most affected by HIV, tuberculosis and
    malaria have a critical role in advocacy, implementation and
    innovation. It is a privilege to be here with Elton John. He and his
    foundation have been doing remarkable work supporting community groups
    who provide HIV counseling and testing, care, treatment and other
    services to those often left behind and are discriminated against--
    which also helps break down stigma that is the enemy of the battle to
    end the HIV epidemic.
    3. driving innovation to bring new solutions, ideas and partners to the
                       fight against aids, tb and malaria
    Innovation Hub
        New innovations can create unprecedented opportunities to
    accelerate prevention and treatment interventions for dramatic impact.
    The Global Fund is working to capture and catalyze innovation from the
    private sector, public sector, the faith community and community-based
    organizations.
        The Global Fund is working with partners to leverage private sector
    expertise to increase the effectiveness of programs we finance and
    address common implementation challenges. To do so, we have established
    an Innovation Hub with a focus on engaging new and complementary
    actors. The Global Fund Innovation Hub seeks not just partnerships with
    the private sector, but partnerships for solutions.
        The Innovation Hub is a platform that allows us to bring together
    partners that will yield new solutions in the fight against the three
    diseases. It focuses on three primary areas: procurement and supply
    chain management, finance systems and program quality. As we look
    towards implementing countries to take on greater levels of
    responsibility for financing programs, we are opening new entry points
    and creating greater space for private finance and expertise.
        We are looking for innovation that will yield significant results
    in our efforts to fight the three diseases, improve health outcomes and
    strengthen country systems. We are also broadening our engagement
    modalities with the private sector--from cash and pro-bono, to
    innovative ``low-bono'' models. We are focusing on three main priority
    areas: finance and risk management; procurement and supply chain
    management and quality of service delivery. We already have models that
    are working. Coca-Cola uses its distribution and marketing expertise to
    strengthen health product supply-chains in countries in Africa. With
    SAP, we have a multi-country approach with pilots launched in 6
    countries on a grant management dashboard tool designed to help
    implementers manage their programs better. To improve financial and
    risk management capacities in programs we fund, a partnership with
    Ecobank provides capacity building support focused on Nigeria and South
    Sudan. With Munich Re, the partnership is focused on vulnerable
    communities with potential solutions such as life insurance, critical
    illness cover, living benefit products, universal heath covers and
    improved access to health.
        We are also aiming to improve the quality of health programs and
    services by implementing innovations in management that increase
    efficiency with existing funding. We are looking at health facilities
    that perform extremely well and how we can replicate their practices in
    other sites. Adopting country-driven innovations can yield very
    material savings. Initial evidence suggests that these approaches have
    the potential to significantly improve effectiveness by 20 percent or
    more on key program outcomes such as case detection and treatment
    adherence. We are working closely with PEPFAR, the Gates Foundation,
    the World Bank and others on this important endeavour.
    Procurement for Impact
        The Global Fund is also leading the world and other donors to
    clarify global demand forecasts, lower costs, improve suppliers'
    production plans, and make procurement more efficient for HIV/AIDS,
    tuberculosis and malaria interventions and commodities. This is perhaps
    the single most effective way to achieve long-term savings and stretch
    critical Global Fund and U.S. taxpayer dollars. Called Procurement for
    Impact, this major new initiative of the Global Fund is working to
    reduce costs through more efficient and effective purchasing and supply
    chain management. The initiative has saved $500 million since 2013--
    money that is being reinvested by countries for greater impact. Now
    that is value for money. It has also improved monthly on-time delivery
    of commodities from 38 to 68 percent over the same time period.
    E-marketplace for health commodities
        Finally, I'd like to note the exciting new work being done on the
    creation of an innovative E-marketplace for health commodities, a
    system being developed in conjunction with PEPFAR and private sector
    funding and expertise. Although still in its initial stages, this open-
    source, cloud-based system has the potential to revolutionize the
    procurement of health commodities, not just for the Global Fund but for
    all global health providers. It would allow countries to independently
    input global health product specifications and delivery dates, and then
    have a centralized data base offer up commodity and price options in
    just the same way that we can order and compare prices online for books
    or plane tickets. This would provide countries with procurement
    autonomy in their ordering without sacrificing cost and quality
    controls--and without requiring sophisticated and expensive in-country
    procurement expertise. The marketplace would also provide full
    transparency, and therefore significantly reduce opportunities for
    corruption and provide tracking information to reduce diversion.
    Falsified and sub-standard medicines
        In recent years, the issue of falsified and sub-standard medicines
    has become an increasingly important issue, with a recent report
    estimating that up to 30 percent of anti-malarials circulating in sub-
    Saharan Africa are of inferior quality. The Global Fund closely
    monitors and responds to incidences of falsified medicines by
    continuing market surveillance activities. The Global Fund also helped
    to create the Global Steering Committee for Quality Assurance of Health
    Products which includes regulatory and law enforcement agencies, non-
    government organizations and others to contribute to an enhanced drug
    quality assurance framework, supply chain integrity and expanded public
    awareness.
                                   conclusion
        As Bill Gates recently stated before this subcommittee, ``If you
    look at a disease like HIV, through PEPFAR and the Global Fund,
    millions of lives are being saved, and if you cut those programs back
    there simply won't be enough medicine to keep people on treatment. The
    United States has been an incredible leader there. It's done a great
    job of drawing other governments in. It's only through our generosity,
    though, that other money is activated. So if we cut back I think we'll
    see other funds going away, as well.''
        U.S. leadership is essential and we will see a resurgence of
    infectious diseases if our commitment to these diseases waivers. But
    more importantly, we have an historic opportunity to end these diseases
    together. This is a goal and challenge worthy of the American people
    and this great body. Together, we can prevent new infections, save
    millions of lives, support resilient health systems, and create
    healthy, stable and productive families, communities, and states.
        Once again, on behalf of the Global Fund, I thank you for the
    opportunity to testify here today. I look forward to answering your
    questions.

        Senator Graham. Dr. Warren.

                      SUMMARY STATEMENT OF DR. RICK WARREN

        Dr. Warren. Chairman Graham, Ranking Member Leahy, members
    of the subcommittee, thank you for inviting me to testify here
    today. I have so much respect and admiration for all of you,
    agree that the 150 Account is probably the most effective
    account in the United States budget, and what you are doing
    matters to our nation, it matters to the world, and it actually
    is a matter of life and death to millions of people around the
    world.
        I am not just Pastor of Saddleback Church. I am the Founder
    of The Global P.E.A.C.E. Plan, which has sent teams to 197
    countries. In my own church 24,869 of my members have served in
    197 countries, which is 57 more countries than the Peace Corps
    has served.
        By the way, before I address the matter of global health, I
    just want to say thank you for your previous hearing on
    protecting religious liberty abroad. It is a big issue and I
    have spoken to that in my printed remarks.
        As you know from your hearings previously, we are making a
    lot of progress on the pandemics like HIV, malaria, and TB, and
    while the momentum is headed in the right direction, now is the
    time to move for eradication.
        A lot of times in the third quarter of a game, people say,
    well, we know how the outcome is going to happen, so let's just
    let off the pedal and leave the game. We cannot do that now.
    The Super Bowl is a good example of what happens in the last
    second of a game.
        I believe it will take three catalytic factors in order to
    eradicate HIV, malaria, and TB. First, we must form a new
    perspective on foreign assistance. Second, we must forge new
    partnerships in distribution, and third, we must fund a new
    priority in the budget which would include ending
    sequestration. I have covered this in detail in my written
    testimony.
        I want to spend most of the time on partnerships and new
    distribution, but let me just make a comment on forming a new
    perspective on assistance. There are voices today that
    sincerely believe that we should either cut back or eliminate
    all foreign assistance.
        This idea resonates with a lot of voters for two reasons.
    First, they have no idea that this amount is actually less than
    1 percent of the budget. They think it is a big amount. It is
    not. Second, they do not realize the strategic value of foreign
    assistance. They have never considered that the right kind of
    foreign assistance, especially for health, education, and
    development, may be our most effective and cost efficient
    strategy for security against the next generation of terrorism.
    This is what I mean by ``new perspective.''
        Proverbs 3:27 of the Bible tells us it is morally wrong to
    withhold assistance from those who need it when we have it in
    our power to help them. There are also strategic reasons why it
    would be shortsighted and unwise to cut back our assistance in
    global health.
        First, when America saves the lives of people dying from
    preventable diseases, we make friends. That is obvious. Around
    the world I have often been told, ``Please thank Americans for
    PEPFAR, it saved my husband's life, it saved my wife's life, my
    children's lives, it kept our family from economic disaster,
    and we will always be grateful to America, and we pray for
    you.''
        When we make friends like that by saving lives, potential
    enemies are turned into grateful allies. If someone saves your
    life, you have zero desire to terrorize them.
        In my travels I have observed that when poor countries are
    overwhelmed by these pandemics and they are stuck in poverty
    and have no capital to create opportunities, they get resentful
    of nations with abundant resources that ignore their plight,
    and that resentment makes them ripe for angry ideologies.
        It is far more effective, far more cost effective, far
    cheaper for Americans to send medicine to make friends now than
    to send troops to fight enemies later. Medicines cost less than
    tanks. The resources that we budget for humanitarian relief,
    health programs, economic development, education, and training
    can really save us from spending far, far more to send soldiers
    when resentment boils over.
        That is the ``new perspective'' I am talking about. We need
    to frame this not as just it is some charity that we do. It is
    strategically smart for America's security and safety to help
    people who are in pain.
        The second catalytic factor in eradicating preventable
    diseases is we have to forge new partnerships in distribution.
    Sometimes you have to team tackle a player on a football field,
    he is so big one person cannot take him down. This is what I
    call the three legs of the stool. A one legged stool will fall
    over and a two legged stool will fall over, but a three legged
    stool will stand.
        I have been invited to speak at Davos World Economic Forum
    multiple times, and every time I hear people saying we need
    public and private partnerships. Whenever I hear that, I say
    you are right, but you are only two-thirds of the way, you are
    leaving out the biggest sector, and that is the faith sector.
    It dwarfs the other two sectors.
        Let me put this into perspective. There are 600 million
    Buddhists in the world. There are 800 million Hindus in the
    world. There are 1.5 billion Muslims in the world, and there
    are 2.3 billion Christians in the world.
        The actual number of people without faith is quite small
    outside of Manhattan and parts of Europe.
        Dr. Warren. Most people have a faith. If you want to talk
    about distribution, you have to use faith communities. I could
    take you to 10 million villages around the world where the only
    thing in it is a church. In much of the world, the church is
    the only social sector outside of the capital, and even if we
    have all the meds for TB, AIDS/HIV, malaria, and all the other
    diseases, the issue of distribution will not be solved unless
    we mobilize local churches.
        Let me just give you one illustration. At the end of
    President Bush's term of office, he invited me to be the
    closing speaker at the Global Summit on Malaria. I said I will
    come if I can bring some pastors from Africa, so I did. At the
    end of the talk, I stood up and I said I am going to show you
    three slides that show you why you cannot solve any global
    problem without the faith community.
        I said let me just show you one example. I have been in 164
    countries, but this is just one. Rwanda. We went there and we
    said what would you like. They said the western province of
    Rwanda needs health care.
        We went there. I put up a sign, a map of Rwanda, western
    Rwanda. I said here are the three hospitals for about a million
    people. It is a two day walk to any of these hospitals. That is
    not good enough health care, to have to walk two days to get
    your health.
        I said now, by the way, two of these three hospitals, they
    are faith based, so you would not even have them if it were not
    for the church.
        I put up the next slide, I said here are 18 clinics. I said
    these 18 clinics, now it is only a day's walk, but if you have
    been to developing countries, a clinic is often a bottle of
    aspirin on a shelf or even less than that. I said that is
    better than three hospitals. I said by the way, 16 of those are
    faith based, and you would not have those without the church.
        I said watch this. I put up the third map. It was covered
    with dots. Here are the over 600 churches in this division.
    Now, where would you like to get your health care, two days'
    walk, one day's walk, or five minutes away?
        Melinda Gates was sitting in the front row. She came up and
    said, ``I get it, Rick. The church could be the distribution
    center for health care.'' I said ``Melinda, it has been for
    2,000 years!''
        Let's put this in perspective. The church invented the
    hospital. If we are going to absolutely eradicate these
    diseases, we have to do a combination of the public sector, the
    private sector, and the faith sector, the three legs of the
    stool.
        Again, I would encourage, if there is any way we can end
    sequestration, I am in favor of that. There are a lot of areas
    that I think we could cut the budget. This is one area of the
    budget that should be increased for strategic reasons.
        Thank you.
        [The statement follows:]
                     Prepared Statement of Dr. Rick Warren
        Chairman Graham, Ranking Member Leahy, and members of the
    subcommittee: Thank you for inviting me to testify before your
    distinguished subcommittee that oversees such far-reaching
    responsibilities around the world. I want to begin by saying that I
    have so much respect and admiration for each of you and your leadership
    in this subcommittee, and it is an honor to call many of you friends.
    What you are doing matters to our Nation, it matters to our world, and
    it is literally a matter of life and death for many people around the
    world. I commend this subcommittee for being a model of bipartisan
    leadership and problem solving on so many critical issues including
    global health.
        My name is Rick Warren and in addition to being the founding pastor
    of Saddleback Church in California and author of The Purpose Driven
    Life, I lead the Purpose Driven Network of Churches, which has trained
    over 400,000 pastors, priests, and ministers of congregations in 164
    countries. I am also the founder of the Global P.E.A.C.E. Plan which
    has sent teams to serve in 197 countries. P.E.A.C.E. is an acrostic for
    Promote reconciliation, Equip ethical leaders, Assist the poor, Care
    for the sick, and Educate the next generation. In the past 12 years,
    I've sent 24,869 of my church members to serve in 197 countries (that's
    57 more countries that the Peace Corps has served).
        Before I address the issue of global health and development, I want
    to first commend you and thank you for your previous hearing on
    Protecting Religious Freedom Abroad. If America doesn't take the
    leadership on that issue, no one will. It is not by accident that
    religious liberty is called America's ``first freedom.'' It's what made
    our Nation unique. Religious liberty and the freedom of conscience is
    the first phrase, of the first sentence, of the first amendment in our
    Bill of Rights. Freedom of religion comes before freedom of speech,
    freedom of the press, freedom to assemble, the right to bear arms, and
    every other freedom. That's because it is the cornerstone of all our
    freedoms. If we don't have the freedom to believe and practice our
    beliefs, then we don't need freedom of speech or the freedom of the
    press or the freedom to assemble. All the other freedoms flow out of
    our first freedom. We must preserve this in America at all costs. No
    other country was founded on this freedom, and we must champion
    religious liberty and freedom of conscience around the world.
        I'd also like to thank and congratulate Senator Blunt for his
    successful sponsorship of the Near East Religious Freedom Act. Last
    year, King Abdullah of Jordan asked me to convene a 2 day conference in
    Amman, Jordan on ``Violence against Arab Christians'' in light of
    church bombings and beheadings in Egypt, Syria, and other Arab nations.
    I brought the top Arab Christian leaders from all 22 Arab nations
    including Coptic, Catholic, Evangelical, Orthodox, Pentecostal, and
    other Christian leaders. Those Middle Eastern leaders asked me to thank
    you.
        Now to the issue of global health. As you know, from your hearing
    on development with my friends Bill Gates & Scott Ford, we have made
    enormous progress toward ending pandemics like HIV, malaria and TB. Now
    is the time--while the momentum is headed in the right direction--to
    step up our efforts and eradicate these preventable diseases in this
    generation. How will that be possible?
        It will take 3 catalytic factors:
            1. We must form a NEW PERSPECTIVE on foreign assistance.
            2. We must forge NEW PARTNERSHIPS in distribution.
            3. We must fund a NEW PRIORITY in the budget.
        I'd like to spend most of my time talking about the second factor--
    new partnerships in distribution--but let me first explain what I mean
    by a new perspective.
                  we must form a new perspective on assistance
        There are voices today who sincerely believe that in an age of
    budget restraints, America should eliminate most, or even all, of our
    foreign assistance. This idea resonates with many voters for two
    reasons: First, most Americans are completely unaware that foreign
    assistance is less than 1 percent of our national budget. Second, few
    realize the strategic value of foreign assistance. They've never
    considered that the right kind of foreign assistance--especially for
    health, education, and development--may be our most effective and cost-
    efficient strategy for security against the next generation of
    terrorism. This is what I mean by ``a new perspective.''
        Proverbs 3:27 tells us it is morally wrong to withhold assistance
    from those who need it when we have the power to help them. But there
    are also strategic reasons why it would be shortsighted and unwise to
    cut back our assistance in global health.
        First, when America saves the lives of people dying from
    preventable diseases, we make friends for our Nation. Around the world
    I have been often told, ``Please thank Americans for PEPFAR. It saved
    my husband's life and kept our family from economic disaster. We will
    always be grateful to America, and we pray for you.''
        When we make friends by saving lives, potential enemies are turned
    in to grateful allies. If someone saves your life you have zero desire
    to terrorize them. In my travels I've observed that when poor countries
    are overwhelmed by pandemics, stuck in poverty, and have no capital to
    create opportunities, they become resentful of nations with abundant
    resources that ignore their plight. This resentment makes them ripe for
    angry ideologies of revenge and retaliation.
        It's far more cost-effective and cheaper for America to send
    medicines to make friends now, than to send troops to fight enemies
    later. Medicines cost less than tanks. The resources that we budget for
    humanitarian relief, health programs, economic development, education,
    and training can save us from spending far more to send soldiers when
    the resentment boils over.
        Second, the rest of the world looks to America for its model of
    generosity. When we are generous, it unleashes other funds around the
    world. If we reduce our commitment to the sick and the unfortunate, we
    can be certain that other nations and entities will cut back too. We do
    not want to be the model for self-centeredness.
        Now I realize this is not the appropriate subcommittee for my next
    comment, but I'd like to get it on record that if we want Americans to
    be personally generous with the needy, we need a tax code that
    incentivizes generosity, rather than capping it. But that's another
    hearing.
        The second catalytic factor to eradicating preventable diseases is:
                 we must forge new partnerships in distribution
        The reason we must do this is because even if we had enough
    medicines and resources to eradicate all preventable diseases, there
    would still be the problem of distribution to the farthest corners of
    the earth.
        Sometimes a football player is so huge that the opposing team has
    to gang up and ``team tackle'' that player. He won't be brought down by
    one player. It takes a partnership of multiple players to defeat him.
    The same is true of the globe's greatest problems: extreme poverty,
    pandemic diseases, illiteracy and education, conflict and corruption.
    No government can solve all these problems by itself and neither can
    any business or non-governmental organization (NGO).
        I've been invited to speak several times at the Davos World
    Economic Forum and every time I go I hear the common refrain ``We must
    have public and private partnerships'' to solve the world's biggest
    problems. While I agree that is certainly important, my reply is always
    the same; ``You're close to the solution, but you're missing the third
    leg of the stool! You are implying that there are only two sectors of
    society when there are actually three, and you are leaving out the
    largest sector by far: the faith sector.
        A one-legged stool, or even a two-legged stool, will fall over. For
    balance and stability you must have three legs. In addressing global
    problems we need a three-legged stool. We must engage the public sector
    (government), the private sector (businesses/NGOs) and the faith sector
    (local houses of worship). Each sector brings unique strengths to the
    table and each is incomplete without the others.
        Governments set national priorities and agendas. Their role is to
    protect the people, preserve freedom, provide opportunity, and promote
    prosperity. Businesses and the private sector also have a vital
    function in attacking global problems. They provide capital
    investments, expertise, technology, and management skills.
        But the faith sector brings several critical missing elements to
    the table that no government nor NGO nor business will ever have. One
    of these elements is universal distribution. Many people will be
    surprised to learn that the largest international network is not
    Walmart or McDonalds, but the Christian church. The church is a network
    that links people in every country, every social or ethnic group, and
    every economic strata together. It includes one out of every 3 people
    on the planet, and has literally millions and millions of local
    outposts around the globe.
        The Church--in all its expressions--Catholic, Evangelical,
    Pentecostal, Protestant, and many others--is unequivocally the largest
    and most widespread network in the world. Nothing else is even a close
    second. With 2.3 billion members of local congregations, the Church is
    larger than China and India combined. The Christian church speaks more
    languages than the United Nations, and is represented in thousands of
    subgroups of people you've never heard of.--The Church was global
    hundreds of years before anyone thought of globalization.
        I could take you to millions of villages around the world where the
    only civil institution that exists there is a local church. They have
    no school, no clinic, no post office, no store--but they have a church!
    In many nations, outside of the capital, the only service organization
    you can find anywhere is a church. In most of the world, you cannot
    talk about community development without including the church, because
    in most villages, the church is the community!
        Local churches also offer the largest pool of motivated voluntary
    manpower, long-term grassroots commitment, a motivation to help others,
    and built-in credibility with local residents.
        Governments are limited by geography and the sovereign rights of
    other nations. Businesses, even multinationals, must deal with the
    barriers of local customs and languages . But indigenous congregations
    face none of these barriers. We must partner with churches for
    distribution of healthcare and other services. Saddleback church has
    been doing this around the world for 12 years and the results have been
    stunning. It's cheaper and faster than any NGO.
        Finally, the 3rd catalytic factor needed to eradicate preventable
    diseases is:
                   we must fund a new priority in the budget
        While there are many expenditures in our national budget that could
    be reduced, I believe we need to increase our foreign assistance for
    global health, for the reason that I stated earlier. From what I've
    witnessed around the world, America is getting a great return on
    investment from your appropriations. The benefits, both to our country
    and other nations, are many times greater than the fraction of our
    budget that goes to foreign assistance.
        Through the P.E.A.C.E. plan in 197 nations, I've become friends
    with many presidents and national leaders. I am including in this paper
    a list of suggestions that I've heard over the years:
                    what kind of assistance is most helpful?
        1. Without targeting economic development to fight poverty, aid can
    never be sustainable.
        2. Funding should reflect true accountability in which both parties
    are held accountable. This helps to improve country ownership of the
    management, measurement, monitoring and planning.
        3. ``Smart'' aid supports alignment with national plans that are
    committed to development and fighting poverty, leaving no one out from
    benefitting. (A good example of this is Rwanda's national health
    sector's strategy that is synergistic with their economic development
    and poverty reduction strategy (EDPRS).
        4. Aid should respect the culture and the history of the country it
    aims to support, recognizing that the best options are always informed
    by the needs of the people intended to benefit from them expressed by
    themselves.
        5. Countries are hungry for data collection systems, and
    information and communication technologies (ICT) that can be used for
    improved evidence-based policymaking in all sectors. This would help
    assure not just improved accessibility to services but also the quality
    of the services provided.
        6. The most helpful assistance focuses on sustainable human
    development at the grassroots level. The most universal grassroots
    organization of earth is the local house of worship. Churches are the
    only social structure in millions of villages around the world.
        7. Funding must target both the upstream causes of ill-health (i.e.
    socioeconomic determinants) and the symptoms of poverty (i.e. disease
    and disability.)
                                   conclusion
        Ten years ago, on October 20, 2005 the Associated Press quoted
    Senator Majority Leader Bill Frist as saying, ``The American people
    expect and deserve a United States Senate that is purpose driven, and
    gets results. We are called upon to govern with meaningful solutions.''
    I believe that is still true today, and I'm certain that you believe
    that too. Thank you Mr. Chairman, Senator Leahy, and thank you
    subcommittee members for your time. I look forward to working with any
    of you in forming a new perspective on assistance, forging new
    partnerships in distribution, and funding a new priority in the budget.
    May God bless you all.

                                   ADDENDUM 1

               overview of hiv initiative of the p.e.a.c.e. plan
               six ways any c.h.u.r.c.h. can serve those with hiv
        Care for and Support the Sick.--Churches are commanded to care. It
    is their calling. Love leaves no choice! Local congregations are the
    only caring organization found in almost every community around the
    world. Members can offer physical and emotional care in homes
        Handle Testing and Counseling.--Churches are the most trusted
    organizations in communities, so people may be more willing to be
    tested and counseled there. Just being tested has proven to promote
    healthier behavior. Members can be trained to give medical, emotional
    and family counsel to those receiving results from their testing.
        Unleash a Volunteer Labor Force.--Churches have the largest
    volunteer labor force on the planet representing more than 2 billion
    members. What if half of those could be mobilized? There aren't enough
    professionals in the world to teach prevention, administer treatment
    and offer care to those who need it. There is an enormous pool of
    untapped talent and energy sitting unused in churches waiting to be
    mobilized.
        Remove the Stigma.--Churches must embrace infected individuals,
    remove abuse and alienation and replace rejection with mercy. They can
    provide faith, hope, love, forgiveness and grace--spiritual support,
    which neither business nor government are able to offer.
        Champion Healthy Behavior.--HIV/AIDS is complex and yet
    preventable. Churches have the moral authority to promote healthy
    behavior and to offer moral imperatives for the family and teach the
    moral motivation for abstinence and faithfulness. To resist peer
    pressure and relapse, faithfulness requires faith
        Help With Nutrition and Medical Adherence.--For treatment to become
    universal, we must develop a church-supported treatment model with peer
    treatment coaches, Organizations come and go, but churches are
    permanent community fixtures. Members can be trained to distribute HIV/
    AIDS medications and support essential nutrition. The church can offer
    pre-treatment preparation, treatment education, adherence support,
    direct observation therapy (DOT) and treatment coaching to the entire
    family.

                                   ADDENDUM 2

          western rwanda healthcare initiative of the p.e.a.c.e. plan

        Senator Graham. Thank you very much, Rick. Sir Elton John.

                      SUMMARY STATEMENT OF SIR ELTON JOHN

        Sir Elton. Thank you very much. Mr. Chairman, Senator
    Leahy, and members of the subcommittee, thank you for the
    opportunity to testify this morning.
        It is a very daunting task sitting at a table with three
    amazing people who are in the trenches every day fighting this
    disease and doing incredible work. I am very humbled by being
    here and humbled amongst the company I am keeping.
        In 2003, at the invitation of Senator Ted Kennedy, I had
    the honor of speaking before the Senate Health Committee in my
    capacity as the Founder of the Elton John AIDS Foundation.
        I created the Foundation in 1992 to address the dire need
    to provide basic services and support to those dying from AIDS.
    Over the past 23 years, we have raised over $321 million to
    fund organizations that provide direct treatment and prevention
    efforts in dozens of countries around the globe.
        When I testified before Congress 12 years ago, almost no
    one had access to antiretroviral medicine in Sub-Saharan
    Africa, where the epidemic was most acute. People were being
    infected and dying by the millions even though we very
    literally had the drugs that could save their lives in our
    hands.
        At that point, 12 million children in Sub-Saharan Africa
    had been orphaned by AIDS.
        African leaders had declared AIDS to be a state of
    emergency worldwide, and more than 30 million people were HIV
    positive. The disease left nothing but despair, ruin, and fear
    in its wake. I saw it with my own eyes as I traveled to the
    hardest hit regions on behalf of my Foundation and our
    grantees.
        Without the funds needed to make life saving drugs
    available in Africa, my Foundation invested in dramatically
    expanding palliative care and a hospice network. Across South
    Africa, Uganda, and Kenya, we helped give a dignified death to
    more than 800,000 men, women, and children. Then we provided
    food, shelter, and basic education to over three million
    orphans left in their wake.
        It was a compassionate response but it did not solve the
    problem. In those years, the epidemic was only escalating,
    until in a time of great need and urgency, a Republican
    President and a bipartisan Majority in the United States
    Congress created PEPFAR, the President's Emergency Plan for
    AIDS Relief.
        Compassionate leaders from both sides of the aisle said to
    the international community, America can and America will lead
    the world in the global fight against AIDS. Today, thanks to
    the unprecedented actions of Congress, an HIV positive mother
    in South Africa can give birth to a healthy HIV-free baby whom
    she can live to raise.
        Today, thanks to the generosity of the American people, 9.4
    million men, women, and children have access to life saving
    antiretroviral treatments. Where there was once despair, ruin,
    and fear, there is now hope, life, laughter, and love.
        PEPFAR has done more than just save lives. It has provided
    basic infrastructure and trained more than 100,000 health care
    workers to prevent future outbreaks in countries like Botswana,
    Tanzania, Kenya, and Uganda.
        Congress' strong support for The Global Fund for AIDS, TB,
    and Malaria has enabled it to generate investments from
    governments and corporations worldwide, and leverage two
    dollars for every one dollar invested by the United States.
    Thereby, expanding its reach and its impact. I am grateful this
    has included up to one billion pounds from the United Kingdom
    over the past 3 years.
        For my Foundation, too, Congress' leadership has been
    transformational. What we once invested in hospice to care for
    the dying has been repurposed to treat the living. My
    Foundation has tested over three million people for HIV in
    Africa and linked more than 400,000 patients to life saving
    treatment on the continent since 2012.
        Combined with efforts funded by the United States, we have
    contributed to the 48 percent global reduction in mother to
    child transmission of HIV. In short, we are no longer bailing
    out a sinking ship, we are helping steer it into a safe harbor.
        Mr. Chairman, because of the actions of this Congress, the
    course of the AIDS epidemic was altered for all of humanity.
    Because the American people had the optimism, the ingenuity,
    and the will to make the difference, the lives of millions of
    people halfway around the world have been saved.
        I am here today with a simple message. The AIDS epidemic is
    not over, and America's continued leadership is critical. There
    is a window of opportunity before us, a window through which we
    can very clearly see the end of AIDS within my lifetime. We
    cannot afford to let the window close.
        If our efforts flag, drug resistance will surface,
    transmission rates will rise, and this disease, which knows no
    boundaries, will once again become a ruthless pandemic with
    disastrous and far reaching consequences.
        I have stood at too many bedsides in America, England, and
    across Africa helplessly watching people die in pain. To bear
    the thought that we might go back to those dark days is
    unthinkable.
        On the other hand, if we continue the historic work of
    PEPFAR and The Global Fund, if we honor the 40 million lives
    lost over the past three decades, then we can and will see the
    day when AIDS is no longer a horrifying global killer, but a
    contained and controlled chronic illness everywhere.
        Mr. Chairman, this is the most powerful legislative body in
    the world, and this Congress indeed has the power to end AIDS.
    You have the power to maintain America's historic commitment to
    leading the global campaign against this disease.
        I am here today to ask you to use that power, to seize this
    window of opportunity to change the course of history. One day
    soon, I hope to extend my thanks to you, to this Congress, to
    the United States of America, not only for fighting this
    disease, but for ending it once and for all.
        Thank you.
        [The statement follows:]
                      Prepared Statement of Sir Elton John
        Mr. Chairman, Senator Leahy, and members of the subcommittee, thank
    you for the opportunity to testify this morning.
        In 2003, at the invitation of Senator Ted Kennedy, I had the honor
    of speaking before the Senate HELP Committee in my capacity as the
    founder of the Elton John AIDS Foundation.
        I created the Foundation in 1992 to address the dire need to
    provide basic services and support to those dying from AIDS. Over the
    past 23 years, we have raised over $321 million to fund organizations
    that provide direct treatment and prevention efforts in dozens of
    countries around the globe.
        The first time I testified before Congress 12 years ago, in sub-
    Saharan Africa, where the epidemic was most acute, almost no one had
    access to antiretroviral medicine. People were being infected and dying
    by the millions even though we very literally had the drugs that could
    save their lives in our hands. At that point, 12 million children in
    sub-Saharan Africa had been orphaned by AIDS. African leaders had
    declared AIDS to be a ``state of emergency.'' Worldwide, more than 30
    million people were HIV-positive.
        The disease left nothing but despair, ruin and fear in its wake. I
    saw it with my own eyes, as I traveled to the hardest hit regions on
    behalf of my Foundation and our grantees. Without the funds needed to
    make lifesaving drugs available in Africa, my Foundation invested in
    dramatically expanding palliative care and a hospice network. Across
    South Africa, Uganda and Kenya, we helped give a dignified death to
    more than 800,000 men, women and children. Then, we provided food,
    shelter and basic education to over 3 million orphans left in their
    wake. It was a compassionate response but it didn't solve the problem.
        In those years, the epidemic was only escalating, until--in a time
    of great need and urgency--a Republican president and a bipartisan
    majority in the United States Congress created PEPFAR--the President's
    Emergency Plan for AIDS Relief. Compassionate leaders from both sides
    of the aisle said to the international community: America can, and
    America will, lead the world in the global fight against AIDS.
        Today, thanks to the unprecedented actions of Congress, an HIV-
    positive mother in South Africa can give birth to a healthy, HIV-free
    baby who she can live to raise.
        Today, thanks to the generosity of the American people, 9.4 million
    men, women and children have access to life-saving antiretroviral
    treatment.
        Where there was once despair, ruin and fear--there is now hope,
    life, laughter and love.
        PEPFAR has done more than just save lives--it has provided basic
    infrastructure and trained more than 100,000 healthcare workers to
    prevent future outbreaks in countries like Botswana, Tanzania, Kenya,
    and Uganda.
        Congress' strong support for the Global Fund for AIDS, TB & Malaria
    has enabled it to generate investments from governments and
    corporations worldwide and leverage $2 for every $1 invested by the
    United States, thereby expanding its reach and its impact. I am
    grateful this has included up to 1 billion pounds from the United
    Kingdom over the past 3 years.
        For my Foundation too, Congress' leadership has been
    transformational.
        What we once invested in hospice to care for the dying, has been
    repurposed to treat the living. My Foundation has tested over 3 million
    people for HIV in Africa and linked more than 400,000 patients to
    lifesaving treatment on the continent since 2012.
        Combined with efforts funded by the United States--we've
    contributed to the 48 percent global reduction in mother-to-child
    transmission of HIV.
        In short, we are no longer bailing out a sinking ship, we are
    helping steer it into safe harbor.
        Mr. Chairman, because of the actions of this Congress, the course
    of the AIDS epidemic was altered for all of humanity. Because the
    American people had the optimism, the ingenuity, and the will to make a
    difference, the lives of millions of people half way around the world
    have been saved.
        But I'm here today with a simple message: The AIDS epidemic is not
    over. And America's continued leadership is critical.
        There is a window of opportunity before us--a window through which
    we can very clearly see the end of AIDS--within my lifetime.
        We cannot afford to let that window close. If our efforts flag,
    drug resistance will surface, transmission rates will rise, and this
    disease, which knows no boundaries, will once again become a ruthless
    pandemic with disastrous and far-reaching consequences. I have stood at
    too many bedsides--in America, in England and across Africa, helplessly
    watching people die in pain, to bear the thought that we might go back
    to those dark days.
        On the other hand, if we continue the historic work of PEPFAR and
    the Global Fund . . . if we honor the 40 million lives lost over the
    past three decades . . . then we can and will see the day when AIDS is
    no longer a horrifying global killer, but a contained and controlled
    chronic illness.
        Mr. Chairman, this is the most powerful legislative body in the
    world. And this Congress indeed has the power to end AIDS. You have the
    power to maintain America's historic commitment to leading the global
    campaign against this disease.
        I am here to ask you to use that power. To seize this window of
    opportunity. To change the course of history.
        And one day soon, I hope to extend my thanks--to you, to this
    Congress, to the United States of America--not only for fighting this
    disease, but for ending it--once and for all.
        Thank you.

        Senator Graham. And ended right on time. It is amazing.
    After this, how would you like to vote against the 150 account?
    What would you say? The terrorists want you to vote no. That is
    the only thing I can think of.
        Mark, name countries that could do more to support The
    Global Fund that are not.
        Dr. Dybul. Thank you, Mr. Chairman. It is a long list. I
    just came from one, China, actually, arriving last night. They
    once actually received resources from The Global Fund but now
    are giving. They have transitioned out.
        Senator Graham. Could they do more?
        Dr. Dybul. They can, and we are working with them to invest
    more.
        Senator Graham. What about the Gulf countries?
        Dr. Dybul. The Gulf countries could definitely do
    considerably more in the fight against these three diseases.
    Parts of Southeast Asia. Thailand is transitioning from a
    recipient of The Global Fund----
        Senator Graham. We are not asking people to give who have
    their own problems. We are talking about people who have some
    economic ability to give that are not.
        Dr. Dybul. These countries actually do have considerable
    economic ability, and they are stepping up.
        Senator Graham. What about Europe? How would you rate
    Europe's response?
        Dr. Dybul. Europe is doing quite well in a number of
    places, the U.K., as Sir Elton John mentioned. France is the
    second largest contributor.
        Senator Graham. Where is Germany?
        Dr. Dybul. Germany is increasing its commitment, and is
    currently number six. Japan is number five.
        Senator Graham. In terms of economic power in Europe, how
    does Germany rank?
        Dr. Dybul. They are certainly number one.
        Senator Graham. They are number five in giving and number
    one in economic----
        Dr. Dybul. To The Global Fund, they have actually just
    increased significantly their commitment, for example, to GAVI,
    and they have increased their commitment to us and have made a
    commitment to do even more.
        Senator Graham. Thank you very much. Rick, these churches
    with their new distribution network, will you take anybody that
    comes?
        Dr. Warren. Absolutely. In fact, after I made that
    presentation at President Bush's malaria conference, I said I
    am going to prove that I can do it faster than any NGO or any
    government. I went to that area of Rwanda and I asked pastors
    ``Would you be interested in us training your people in basic
    health care?'' because you are never going to have a doctor in
    your village, there will never be enough doctors for every
    village in the world. Eighteen pastors said yes. I said grab
    two people from your congregation and we will start training
    them.
        We started training them in basic health care. The Muslims
    came to us and said, ``Would you train us?'' We said sure. This
    is a human issue, it is not a religious issue. You pick two out
    of your mosques. There were two mosques that chose people to be
    trained.
        That group grew to 60 and we trained them, to 120, 340, on
    and on, we just kept multiplying. This last August I went to
    that area of Rwanda and did a rally for over 3,000 trained
    healthcare workers who each visit seven families a week. They
    make hospital calls. They make house visits.
        We did it with very little money. We started off with
    simply stuff like wash your hands and hang out the sheets to
    dry, how to do sanitation, dressing wounds, stitching wounds.
    They could learn things like how to administer antiretroviral
    (ARVs) and how to do peer coaching, to make sure they do
    compliance with the drugs.
        It can be done, and now we have many other countries asking
    for the same model.
        Senator Graham. Madam Ambassador, what will sequestration
    do to our ability to get this thing put away in terms of AIDS,
    and how would it affect the PEPFAR program if we fully
    implement sequestration?
        Ambassador Birx. I think you heard from my testimony that
    we are doing everything we can to focus every dollar we have
    because there is always more need than there are dollars. We
    take a very strong responsibility in ensuring that we focus the
    dollars we have optimally, but any cut in those dollars----
        Senator Graham. Do you know how much your program would be
    cut by 2021?
        Ambassador Birx. You have mentioned it would be quite
    extraordinary.
        Senator Graham. You need to go find the number. I want you
    to go find the number and tell me.
        Ambassador Birx. We can find that number for you and we
    will get it for you.
        [The information follows:]

        Sequestration at any level would be devastating to the PEPFAR
    program. As the ability to scale life-saving interventions would be
    diminished, more lives would be lost. This is why this Administration
    will continue to work with the Congress to reverse sequestration and
    reduce the deficit through smart, balanced reforms.

        Senator Graham. Yes. I want everybody, including The Global
    Fund, to know. I want you to tell me what the number is. I want
    to tell my colleagues you have X dollars today and you are
    going to have Y dollars tomorrow, and this is what it means.
    You should know these numbers because they are dramatic.
        Sir Elton John, you have been following this battle for a
    long time, you say we are close. What is your worst fear?
        Sir Elton. To be honest with you, my worst fear is that
    stigma will continue to drive the epidemic underground and
    people away from the services they need. We are seeing,
    especially in African countries, the LGBT community suffering
    under Draconian laws. When people living with HIV are
    penalized, they go underground and the disease is spread even
    further. Stigmatizing people because of who they are or because
    they have HIV is the worst thing we can do. For me, that is the
    biggest problem we face.
        Helping people to feel less ashamed, to feel they are okay
    regardless of their identity or status, and not to feel as if
    they are being threatened by their own governments because of
    their sexual orientation is incredibly important.
        Not only is this a human challenge, it is a medical
    challenge as well. They are two sides of the same coin. On the
    one hand, you are telling people they are worthless and not
    treatable or not worth treating. On the other hand, you are
    driving them underground and encouraging the spread of the
    virus.
        A key principle of my Foundation is that nobody should be
    left behind. We live in a world which is so materialistic, so
    narcissistic, the world needs empathy and compassion. The world
    needs leaders to show compassion. The current Pope is someone
    who I revere very much because he is beginning to show so much
    more compassion in a humane way than his predecessors. This is
    vital to the recovery of hope, self worth in this troubled
    world.
        If people are told they are worthless and unloved, then
    where are we as human beings. If Christ was alive today, and I
    believe in Christ, he would be appalled at the way people are
    being stigmatized. We need people to be included and embraced,
    to feel love and compassion. Without that ingredient in this
    whole mixture of medicine and other public health strategies,
    we face an uphill battle.
        I really encourage governments throughout the world who are
    saying that homosexuality is a sin, to understand that they are
    making the disease worse and prolonging the negative
    consequences for their country and their economy.
        It is not just inhumane to people who are suffering from
    this disease, it undermines their efforts toward a more
    sustainable future.
        Senator Graham. From a private sector point of view, have
    you been able to still raise an adequate amount of funds even
    though the economy has been crippled throughout the world or
    are people still giving?
        Sir Elton. People do continue to give and I am very
    grateful for that. But there is also much competition and many
    worthwhile causes in need of charitable support. Private
    funding surely helps but it cannot compare with the immense
    good that the United States Government is doing through its
    generous funding of PEPFAR and The Global Fund.
        It is a matter of education. If I tell people look, here is
    what we are doing and why we believe it will have a tangible
    impact--we are going to offer AIDS education or testing or
    prevention of mother to child transmission services--then
    people will dip into their pockets.
        When we started off with the disease, there were so many
    different foundations. There are not so many left standing now
    but we all work together. I think we are a very strong force. I
    think we are force for good.
        We had a meeting in the Capitol last night. The comradery
    and the feeling I get from the American people is so touching.
    You have to remember that I am British. I came over here in
    1970. This country has given everything to me as a professional
    musician, and as a human being.
        The strength and the willingness to help people in the rest
    of the world has touched me so deeply. It was Ryan White, who
    pointed out to me that my life was in complete disorder. I was
    a drug addict. I was a self obsessed asshole--excuse me.
        Ryan White and his wonderful family turned my life around.
    He was treated very badly by people who were ignorant and
    should have known better, but he never got angry about it and
    he always sought to educate them and forgave them.
        We have to have compassion. We have to have forgiveness. We
    have to have inclusion of everybody, whether it is intravenous
    drug users, prisoners, or people who are gay or transgender. We
    are all human beings. We are all children of God. If we lose
    sight of our own humanity, then we are throwing all of our
    progress and opportunity down the drain.
        I believe in the goodness of the human spirit, look at this
    room. It is a very long-winded answer to your question, but no,
    people are very generous, and if you explain to them where
    their money is going and you show them what it is doing, then
    many will want to help.
        Senator Graham. Thank you. Senator Leahy.
        Senator Leahy. Thank you, Mr. Chairman. I did not think it
    was long-winded at all. It is something that should be heard
    over and over again.
        Ambassador Birx and Dr. Dybul, a question that has been
    asked on dollars, on sequestration. Tim Rieser in my office who
    has worked on this is much more knowledgeable in the nitty-
    gritty than I am. The numbers I am seeing are devastating. They
    are not anywhere near the numbers that Senator Graham and I in
    a bipartisan way supported in the past. Do not sugar coat it,
    make it very clear.
        Sir Elton, you talked about how much less expensive it is
    for prevention than care after the fact. I am aware of that. I
    know Pastor Warren and I have talked about this before. You had
    mentioned about holding the quilt when you were speaking last
    night.
        My good friend I grew up with from Vermont, when he was
    diagnosed--he was actually a public figure in Vermont, and rest
    his soul, when he was first diagnosed, I remember him being
    ostracized. My wife and I came to a large gathering, and people
    were trying to avoid him. This was some years back. My wife is
    a registered nurse. She walked up and gave him a great big hug
    and a kiss.
        He said right to the time he died that changed his life
    because after that, people did not avoid him. They knew my
    wife. She is actually a lot more popular in Vermont than I am.
    They saw Marcelle do that. Keep on pointing that out. It is
    important, even today, people need to hear that.
        We have known about HIV and AIDS for more than 30 years,
    but it is still a huge health issue, even here in the United
    States. We have pockets in the United States where it is
    growing. You would think with all the education, it would be
    cutting back.
        Are there things we should be doing differently in
    combating this? Are we focusing on the right countries? We know
    we are going to have a finite amount of money. How do we spend
    it best? Sorry to put you on the spot, but we are struggling
    with that here.
        Sir Elton. How do you spend it best. You still continue
    much of what you are doing, what PEPFAR is doing, giving the
    HIV testing and antiretroviral drugs to people that do not have
    access to them, building the public health and community-based
    infrastructure in countries where there is little so people
    actually can receive drugs and other essential services and get
    them on a regular basis. A lot of these people live in rural
    areas and need transportation to get to the clinic or community
    health workers to come to their village.
        You have to educate and empower people. Education is very
    important. Prevention is very important. You heard earlier that
    AIDS is the leading cause of death for young people in Africa
    and the second leading cause of death for young people
    worldwide. You have to educate them and you have to spend the
    money very, very wisely. That is all I can say. Mark, do you
    have anything you could add on that?
        Dr. Dybul. It is up to the Senator.
        Senator Leahy. We are seeing increases in parts of this
    country. You would think it would be decreasing everywhere in
    the world. Sir Elton talked about the young women in Africa. We
    are seeing men and women in this country. Where are we missing
    the point?
        Sir Elton. In the rural south, AIDS remains a very big
    problem amongst young gay men, where we see an increase in
    risky behavior. I think maybe because they feel they are not
    going to die.
        Someone mentioned this disease can be a manageable disease,
    you can live with HIV. In this country, which has all the
    sophisticated medicine available, that people are having unsafe
    sex, thinking well, if I have unsafe sex, I am going to be okay
    because there is a pill I can take, not really knowing or
    understanding the consequences of what that pill might do to
    their body in the long run.
        In Africa, many do not have that option. They just want to
    live. Over here, they are able to live because they have the
    medicine available. In Africa and Asia, many still do not have
    the medicine. I think you have seen a rise here, it is
    cyclical, it seems to happen every 10 years, where this disease
    starts to rise again amongst the young, especially where we
    have slowed down on lifesaving AIDS education.
        In the rural south, stigma is a huge problem as well. A lot
    of people do not want to admit they have the disease. A lot of
    people are not being tested. A lot of people walking around do
    not know their status. There is still a lot of fear, even in
    countries as sophisticated as America and my country, Great
    Britain, the same thing is occurring.
        Senator Leahy. Thank you. Dr. Birx, my last question. I
    could ask questions all day long. In the President's fiscal
    year 2016 request for PEPFAR, there is a $300 million impact
    fund. This awards governments to take steps, as I understand
    it, to realign their national programs to combat HIV/AIDS in
    the areas most severely affected.
        I understand you are implementing a similar realignment of
    PEPFAR funds. Some who challenge that say that there are areas
    that are going to receive less funding and that is going to
    have a severe impact. Would you like to explain what is
    happening?
        Ambassador Birx. Thank you, Senator. There are two things
    that we are doing. We are fortunate because of the way Congress
    set up PEPFAR that we have very granular data down to the site
    level, and we know precisely now where there is HIV and where
    there is not HIV.
        What we have found over the last 10 years is a real
    evolution that in areas where there is very little HIV, we have
    excellent coverage of all services, sometimes over 100 percent,
    because people have come over the border to access services.
        In areas where HIV is the most prevalent, where the
    incidence is the highest, say in Kenya around Kisumu and Homa
    Bay, our service delivery is at 30 to 45 percent. We created an
    inequity between areas where we have been over serving and
    areas where we have been substantially under serving the
    population, and working with governments to go through that
    information in a very careful way so that what you just
    described at the end of the question does not happen.
        We are committed, obviously, to maintaining all of the
    services in the areas that are very low burden, and are working
    with governments and Global Fund to ensure there is a safety
    net.
        We are also working and geographically mapping the sites
    down to the absolute precise Global Positioning System (GPS)
    coordinates so that we can tell you there are 10 sites here,
    all within half a kilometer and we only need two. It will be
    much more effective to have two sites there all within walking
    distance, all within less than half an hour walking distance,
    and increase the number of sites in the very high burden areas.
        What is happening, if you are a pregnant woman in Kisumu,
    you have a much lower chance of being diagnosed and linked to
    services than if you are a pregnant woman in Kericho, Kenya,
    and it is only 50 kilometers away. This is the type of work we
    have been doing.
        Senator Leahy. Thank you.
        Senator Graham. Thank you. Senator Daines.
        Senator Daines. Thank you, Chairman Graham. I want to thank
    the passion and compassion of this panel today. It is greatly
    appreciated, and in a city that is not characterized by
    compassion, you bring that here today and we thank you for
    that.
        I was struck, Sir Elton John, by a statement you made in
    your testimony. You said there is a window of opportunity
    before us, a window through which we can very clearly see the
    end of AIDS within ``my life time.'' What is the greatest
    barrier that you see to accomplishing that goal?
        Sir Elton. A reduction in funds for PEPFAR or The Global
    Fund. A reduction would be a huge blow. The world has to step
    up and keep the funding going. Not just the United States but
    everyone. The more funds we get, the more medicine we can get
    to people in need, the more we can decrease the spread of the
    virus. That is the biggest thing we have to do. But its not all
    about money. We have to reduce stigma, too, we have to make
    people feel they are loved and not shamed. That is a big issue.
        I think Rick would agree with me. What he does with his
    church is preach love. That is what we must also do. Along with
    the funding, which is so essential, and that is why I am here
    today and we are all here today saying we hope the United
    States Government, the Senate and the House will at least not
    cut the funding of PEPFAR or The Global Fund because if they
    do, it is going to be a complete disaster. We are going to go
    back to square one and it is only going to get worse.
        It is a mixture of coming together, everybody, some other
    countries have to step up to the plate here as well. America
    cannot do this all on its own. I do not think the EU is doing
    enough. Obviously, China is not doing enough and Japan is not
    doing enough. These are countries that can afford to do better.
        As a panel, we have to go away and say what can we do here
    to make those people step up to the plate and make sure America
    is not the only country in the world that is doing this. They
    cannot do it alone. They can only provide 33 percent of The
    Global Fund.
        As a panel here, we have to go away and say these other
    countries need to step up to the plate, because the funding is
    key to ending AIDS. The more we invest, the more likely we can
    end AIDS, and the more compassion we can show to people living
    with AIDS, the better the money works and the better people
    feel. It is a mixture of both.
        I would not say it was an easy solution because it is not.
        Senator Daines. Thank you for that very thoughtful
    response. I want to pivot over here for a moment and ask Dr.
    Warren a question. In your testimony, you called religious
    liberty ``America's first freedom.'' I think you thanked the
    panel for those protections, fighting for that. It is the first
    phrase of the first sentence in the First Amendment of the Bill
    of Rights.
        Our founding fathers obviously cared a great deal about
    this issue, as I know you do as well, and the fight for
    religious freedom was fundamental in this country's fight for
    independence.
        In your view, what is the state of religious liberty in
    this country today and are we doing enough to protect it?
        Dr. Warren. As I pointed out in my written testimony,
    religious liberty is what America was founded on. It is the
    first freedom. It is not by accident we call it the first
    freedom. It is the first phrase of the first sentence of the
    first paragraph of the First Amendment. It comes before freedom
    of speech, before freedom of the press, before freedom to
    assemble, before the right to bear arms, before every other
    freedom.
        If I do not have the freedom of conscience, to believe what
    I want to believe, I do not need freedom of speech. If I do not
    have the freedom to believe what I want to believe, I do not
    need freedom to assemble. If I do not have the freedom to
    believe and practice my beliefs, I do not need the freedom of
    press.
        That is extremely important. It is all part of what I call
    holistic assistance, that the kind of assistance that is needed
    around the world, meds are not enough. The whole reason we
    started the P.E.A.C.E. Plan is because when we started dealing
    with people with AIDS, we realized they need education, they
    need job training, there are poverty issues here. All of these
    things are holistic.
        As a church, all the things Elton was just talking about.
    C-h-u-r-c-h, we say there are six things a church can do, we
    care for and support the sick. That is the ``C.'' We handle
    testing and counseling. We, you, unleash an army of volunteers.
    We move the stigma which we were just talking about. We
    champion healthy behavior, and we help with nutrition and
    medicine, ``h.''
        It is a holistic approach. You cannot just do one thing. I
    think religious liberty falls into that. I think it is just one
    of the other factors. I have actually had debates on this in
    China.
        Senator Daines. Back to a comment that Elton John made as
    well about the need for funding. You mentioned in your
    testimony that the Tax Code should incentivize generosity.
        Dr. Warren. I do believe that.
        Senator Daines. What do you view as the importance of
    charitable donations to fight poverty, to fight AIDS, global
    health issues in the U.S. and overseas?
        Dr. Warren. As a pastor, I am interested in people's
    personal growth and their growth in character. If you tax me
    and then use that money to help the poor, I do not get any
    credit for it. If you incentivize my generosity and then I am
    generous, I actually grow in character by being generous.
        I am obviously in favor of the Government increasing
    funding for these kinds of things. I think there are a lot of
    things we could cut, and this should be expanded. I believe the
    150 line item really does need to be expanded, and we get more
    bang for the buck.
        I also believe at the same time, and this is probably not
    the committee for it, that we ought to incentivize generosity,
    that the Tax Code should reward generosity rather than cap it.
    Of course, America is the most generous nation there is, but we
    could be even more generous if we create a system that
    encourages it.
        What is rewarded is repeated.
        Senator Daines. Thank you. Thanks, Mr. Chairman.
        Senator Graham. Senator Coons.
        Senator Coons. Thank you, Chairman Graham. I just want to
    start by thanking you and Ranking Member Leahy for your
    bipartisanship, for your passion, for your commitment to
    ensuring we have thorough and productive hearings, that we look
    hard at the human suffering and at the opportunities we have to
    do good in the world but to do good well, and to do it in a way
    that is sustainable, bipartisan and effective. I really
    appreciate your leadership on these important and valuable
    issues.
        I want to thank the panel today for reminding us of what it
    means to be American and what we can do when we do the best in
    our national spirit and bring our best capabilities to the
    floor.
        Reverend Warren, I appreciate you reminding us we have a
    scriptural injunction to not withhold good from those who
    deserve it when it is in our power to help them.
        Sir Elton John, I appreciated your compelling and personal
    testimony about how a change in your own life was brought
    forward by Ryan White and the dramatic impact you have made
    across the world, and how the two of you in partnership really
    are helping demonstrate what it means to accept, to welcome, to
    love, and to celebrate a wide range of people who are otherwise
    suffering.
        I agree with you that fighting stigma against the LGBTQ
    community in Africa is one of the most important things we can
    do to avoid marginalization, to avoid the spread of the
    disease, and to frankly show your humanity.
        In my limited opportunities as the Africa Subcommittee
    chair the last 4 years, visiting 15 countries, I have tried
    very hard to press that point. The human consequences of
    ongoing oppression based on orientation are very real, and this
    is a very real threat we all face across the world.
        Dr. Dybul, thank you so much for your leadership at The
    Global Fund. As you know, the last Congress, I introduced a
    maternal and child health bill, which I am hoping we will renew
    in this Congress, which would give access to some innovative
    financing techniques to strengthen the amount of resources
    available for maternal and child health.
        That is really the core issue we are talking about here
    today, how to sustain in a difficult budget environment these
    vital investments.
        Tell me if you would, what are the opportunities here for
    innovative financing and what, if anything, do we need to be
    doing legislatively to help facilitate that?
        Dr. Dybul. Thank you, Senator Coons. Innovative financing
    is a big field. One of the most important things to do is to
    get other countries to contribute, as the chairman was
    mentioning, and we are actively pushing on that all around the
    world, not just from the traditional donors but from others. I
    would amend that Germany is actually number four. I got that
    wrong.
        The innovative financing field, and I can give you some
    examples, is an extraordinary opportunity. Social impact bonds,
    we are actually working now in Nigeria, we are forcing
    matching, as I mentioned, they have a $100 million gap to meet
    their bed net need. We have incentive funding. We said we will
    give you $50 million if and only if you cover the other $50
    million. They are going to float a bond, it looks like they
    will float a bond in order to cover that $50 million. That is
    one opportunity.
        Another one is around high net worth individuals. As I
    mentioned, we are actively pursuing high net worth individuals.
    We understand all accounts are constrained, not just in the
    U.S. but all over the world, so we need the private sector to
    be doing more.
        High net worth individuals have enormous wealth, and as I
    mentioned, we have already raised $100 million, and that was
    working with Bill Gates and others, but we see a huge
    opportunity.
        It is not just the money, it is how we are going to use it.
    We are actually trying to build trust funds, private sector
    trust funds that match the public sector investments.
        This does three things. One, it puts more money in. Second,
    often high net worth individuals in a country like Korea,
    China, or Vietnam are among the most influential people in the
    country. They are worth billions of dollars. They are now
    putting pressure on the government to increase their
    contribution because they are putting in money, too.
        The third is around innovative implementation. They are
    saying if I am going to put money in, I want an efficient
    system, so get your efficiency up. Let's work together on
    supply chain, let's work together on procurement systems, let's
    work together on these private sector practices.
        Those types of innovative trust funds are huge
    opportunities for us as we are moving, so countries are funding
    more and more of their own programs. There are many other
    opportunities around innovative finance that we are exploring.
        Countries are doing extraordinary things. Senegal, Kenya
    and Tanzania have some of the most innovative programs where
    they are doing special tax schemes, where they are doing
    special bonds and funds internally to raise money within their
    own countries. It is a huge opportunity. Thank you for raising
    it.
        Senator Coons. I just visited Senegal and Kenya last month.
    As both Sir Elton John and Reverend Warren have shown, the
    capacity of the private sector and charitable individuals to
    make a significant impact here is impressive and we need to
    deploy it further.
        Ambassador Birx, as we saw in the response to Ebola, there
    were Americans and folks around the world who stepped forward
    and made individual contributions in the hundreds of millions
    of dollars that also helped accelerate EU engagement and
    multilateral engagement.
        One of the lessons, I think, of the Ebola experience was
    that PEPFAR resources and training were credited with Nigeria
    being able to rapidly identify and contain the one outbreak in
    Nigeria of Ebola.
        What is the path forward for integrating PEPFAR investments
    into a process of building broader health systems to prepare
    for the next pandemic. Also, please tell us just a little bit
    more if you would about two programs: the ACT program--
    Accelerating Children's HIV/AIDS Treatment, and the DREAMS
    initiative, which you mentioned in passing, but I would love to
    hear a little bit more about in the minute and a half we have.
        Ambassador Birx. Thank you. We have intentionally
    strengthened health systems because without a health system
    that can provide commodities, without a health system that can
    diagnose disease at the laboratory level, without a health
    system that has actual health providers at the health center,
    it was not going to be a functional system.
        It has been very deliberative and very much matched to the
    services we are providing. Of course, a nurse at a health
    center, although she is providing HIV tests and referring
    patients and often treating patients, she is treating all
    patients in the community.
        Although they may be trained and provided by PEPFAR, they
    are there for the community. I think we have seen in every
    other Ebola outbreak that has occurred in the DRC and in
    Uganda, a rapid community response and a rapid medical and
    scientific response because of the infrastructure that has been
    built in the PEPFAR countries.
        Indeed, within Nigeria itself, the Field Epidemiology and
    Laboratory Training Program (FELTP) program there, field
    epidemiologic trained individuals that were there for polio,
    trained by PEPFAR but also utilized in polio became the
    absolute core, but underneath all of that, you have a global
    health core that has been funded and built by PEPFAR around the
    world, thousands of individuals in countries who are part of
    the U.S. Embassy who were also deployed to these countries and
    were the immediate rapid responders.
        On the continent, you have now highly trained public health
    individuals, both host country nationals and direct hire staff.
        ACT and DREAMS are two very exciting pieces because it
    illustrates when you intentionally seek private sector
    engagement around a core program, the private sector will stand
    forward. Having the Children's Investment Fund Foundation come
    forward with $50 million made it possible to achieve the goal
    of doubling the number of children reached by PEPFAR. Only 24
    percent of the individuals, children under 15, in need of
    treatment are receiving treatment. This was really a key
    initiative.
        The DREAMS initiative, which Mark and I are working very
    closely on, really is to empower young women to remain HIV
    free. The statistics are overwhelming. Five percent, 10
    percent, 15 percent, 30 percent prevalence by 20 in areas of
    South Africa. The same thing repeated over and over again.
        This is a program that I have to tell you when I said this
    was high risk and we were entering into unknown territory, this
    is a program that we are relying on, a completely different
    approach, ground up planning, bringing everything to the table
    from social structure to the community structure to the family
    structure to the school structure, to really figure out what
    the most disadvantaged young women need in order to remain HIV
    free.
        We have a lot of what we call monitoring and evaluation
    around it so we can immediately tell what is working and
    transform it into the other countries.
        Thank you for those questions.
        Senator Coons. Thank you. I appreciate the very hard work
    you are doing with PEPFAR and with The Global Fund to make sure
    we have data, we are doing analysis, we are delivering services
    more effectively, as I am sure Elton John's Foundation has
    demonstrated, testing, better testing, better integration at
    the community level that is vital, and as Reverend Warren's
    community health training in Rwanda and elsewhere has
    demonstrated.
        We can do this effectively but we have to do it in
    different ways. We have to do it in a more sustainable way if
    the vision of the end of AIDS in our lifetime is to be
    achieved. Thank you for your great work.
        Senator Graham. Senator Kirk.
        Senator Kirk. I would prefer to call you ``Colonel Birx,''
    to make sure everybody knows about your service to the United
    States Medical Corps.
        When we first met, I told you the story about--I will tell
    other members of the subcommittee. We took the initiative in
    1986 to start off this program. I will say unfortunately
    Senator Leahy is not here, I think he was in the leadership on
    Senate Foreign Ops.
        The story I would tell you is as a staffer, I went to
    Congressman Bob Mrazek of New York, and we started a $25
    million earmark to start the global program in AIDS, as it was
    called. The reason why is the first diagnostic kit was produced
    by Abbott Laboratories, which I will remind everybody is from
    Illinois. We got the results from Abbott. In Kinshasa Central
    Hospital, they had a seropositive rate that was very high,
    according to the models. The epidemic had been going on for
    about 50 years.
        We got very brave Bob Mrazek to go to see Dave Obey, who
    was the chairman of House Foreign Ops, and he said something
    like you know, as those who have worked with Dave Obey, I will
    be God damned if I am going to start a foreign aid disease
    account with an earmark. Luckily, Dave changed his mind to his
    internal credit.
        Dr. Dybul, I see you as the successor to my great partner
    in this work, Dr. Jonathan Mann, who unfortunately we lost in a
    Swiss Air crash with his wife. He told us the need to have a
    multilateral and bilateral program.
        I want to just put before you guys that PEPFAR started with
    bilateral roots and because of those old bilateral roots, it
    does not really work massively enough in Mexico, a country we
    should be concerned about with its disease state. I think that
    shows the advantage of The Global Fund to make sure we are
    working in all countries of great concern.
        I went to school in Mexico. [Speaking in Spanish.] So far
    from God and so near to the United States. We have a long time
    historic problem of Mexico taking direct foreign aid. [Speaking
    in Spanish.] I would say for Mark, it is very important that we
    have the flexibility. The thing Dr. Mann said, he said you have
    to start a bilateral program, do not work with the World Health
    Organization (WHO) Africa, because Nakajima's team is too
    corrupt.
        Deborah, I would say you represent the U.S. Government,
    accountable to Congress and to GAO, for effective delivery. I
    would say to this committee you never know what you are working
    on, this thing started as a $25 million earmark, and now it is
    $4 billion. I saw from the chairman's notes we have spent a
    total of $57 billion on PEPFAR.
        Now I sit back after this work 30 years ago thinking you
    guys are talking about how we have to remind the public that
    the AIDS epidemic is still very much with us. That just warms
    my heart to think of all the positive work. Never in the
    history of mankind has one country given such an investment to
    health care internationally.
        Thank you, Mr. Chairman.
        Senator Graham. Thank you. That was a wonderful question.
        To the stenographer, you are going to have your work cut
    out for you. It is a very earthy committee we have here. Well
    done, Mark. Thank you for your years of involvement.
        Senator Shaheen.
        Senator Shaheen. Thank you, Mr. Chairman. Thank you all
    very much for being here this morning and for the wonderful
    work that you are doing around the world.
        Ambassador Birx and Dr. Dybul, I want to start with you all
    because over 80 percent of new HIV infections among adolescents
    in the hardest hit countries by AIDS are with young women. I
    wonder if you could talk to why that is.
        I think DREAMS is very exciting with Nike and the Gates
    Foundation. Can you speak to what the solutions are as we think
    about how we prevent young women from being infected?
    Ambassador Birx, do you want to go first?
        Ambassador Birx. Thank you. I think this level of
    statistics which NIH has really helped with because it was
    their clinical trials that were done for microbicides that
    really pointed out the unrelenting incidence, the highest rate
    of new infections that we have seen just about anywhere on the
    planet, 4 percent a year, 10 percent a year.
        I think all of us together started looking at this in a
    very detailed way. Mark will also talk about how we have been
    working collectively. It will take a community and it will take
    a village.
        What puts young women at risk is a whole series of factors.
    If there was a silver bullet, we would have already achieved
    it, so there are probably 10 to 15 things that have to be done
    together. A lot of studies have done one thing, they have
    either done education or they have done cash transfer or family
    strengthening.
        What we believe is if you put it together as a combination
    prevention activity, like we are doing for many other parts of
    the HIV program, it will become synergistic so that one plus
    one is now 10, because that is what we need with the number of
    young women.
        In South Africa alone, three million more young women in
    that vulnerable age group than there was at the beginning of
    the epidemic. Three million.
        Senator Shaheen. What you are saying is like so many issues
    that affect women in developing countries, the status of women
    in those societies contributes to the tremendous effect from
    AIDS.
        Ambassador Birx. That is the perfect way to put it.
        Dr. Dybul. That is exactly right, Senator. I often get in
    trouble for insisting that young girls be considered what we
    call a key affected population because the discrimination
    stigma and inequality is really what is driving the issue, and
    that is why it has to be broader than just saying we have
    services available because often they cannot access those
    services. Girls outside school are disproportionately more at
    risk. It is transgenerational sex, it is lack of legal status,
    it is not being even registered when a girl is born. It is a
    whole series of issues.
        As Ambassador Birx said, there is no silver bullet, just
    like there is no one explanation. You can literally go 10
    kilometers apart, 10 miles apart, and you will see a completely
    different reason why a girl is vulnerable. You will see a 10:1
    differential in the vulnerability, so we have to be very
    sophisticated and it has to go community by community.
        We do have some indication of things that can be done, like
    keeping girls in school, that will have, as I mentioned, not
    only an HIV impact, we believe, but then there are ripple
    impacts on culture, so that the girl is expected to go to
    school, she is expected not to get married early or expected
    not to get pregnant early. These are thing that would begin to
    change.
        Perhaps just getting people and communities focused, even
    if we do not know the solutions, focused on finding solutions
    so we can come up with them. We are working on it collectively
    because it has to be a collective effort. It is a group that
    has been left behind and that we have not served properly.
        Senator Shaheen. Thank you. I am actually working on
    legislation to try to make sure that we can get countries to
    register when girls are born.
        Reverend Warren, I want to go to your comments about the
    importance, and they were similar to the chairman's about the
    impact, the strategic impact, that investing in these efforts
    make. They are not just important to the health and welfare of
    people in these countries, but they help us in America.
        I certainly agree with you about the influence of the faith
    sector. I wonder if you could talk about how we could get the
    faith sector more involved in helping to educate and encourage
    Americans to support foreign aid.
        You mentioned many American people do not understand, they
    do not support foreign aid because they think it is much
    greater in terms of the dollar amounts than it is. How can we
    get the faith sector more involved and what do you see that is
    working in that way?
        Dr. Warren. I go back to this idea of assistance and aid
    being holistic. A lot of people do not really know what we do
    when we give money to other countries. They do not know what it
    is going for.
        In fact, usually about all we know what it is going for is
    when we hear we have funded so many jets for a country or so
    many arms for a country. That is what is in the paper. You do
    not hear about what America does for other countries outside of
    arming them. That is a big issue there.
        One of the things that Ambassador Birx mentioned and you
    mentioned, too, was having the right information. I have
    noticed that countries are hungry themselves for data
    collection. When I travel to other countries, I would advise us
    to fund data collection in other countries. That would be a
    wise use of American assistance dollars because without data
    collection, you cannot have a national plan for AIDS reduction,
    malaria reduction, TB reduction, things like that.
        I would say what we need is Smart Aid, and Smart Aid gives
    true accountability on both sides, the donors are accountable
    to do what we say we are going to do, and the receivers are
    accountable on what they receive.
        Smart Aid has an alignment with national plans. Smart Aid
    has good accountability. Smart Aid has data collection systems
    in place, and believe me, the poor countries are not going to
    be able to afford data collection.
        Senator Shaheen. Mr. Chairman, I am out of time, but can I
    ask a follow up to that?
        Senator Graham. Yes.
        Senator Shaheen. I think you are absolutely right about
    that, and I appreciate that. Can you talk a little bit more
    about how we can get the faith sector more involved in helping
    Americans understand why these efforts are so important?
        Dr. Warren. Yes. Senator, it has been my experience that
    the faith community has been more willing to partner than the
    Government has been willing to partner. The Government is more
    afraid of the faith sector than the faith sector is afraid of
    Government.
        If somebody raised up the flag and said we are truly
    talking about partnerships, I have been on the Hill now off and
    on for 20 years, I have heard so much about partnerships and
    nothing ever happens with it unless somebody on my side takes
    initiative.
        I think if there were others who took initiative on the
    other two legs of the stool and even called some symposiums
    together and said look, how do we actually do this. We are
    good. The Government is good at this. Business and health care
    is good at this. What is the church good at? It is good at
    distribution.
        In Africa, they say the pastor sleeps in the same blankets
    as the community. I keep going back to Rwanda because I have
    had 1,200 church members in Rwanda. When the genocide hit in
    1994, every single NGO left the country. It was unsafe. Who
    stayed? The church. The church is the country.
        In most of the world, you cannot talk about community
    development without talking about the church. It is there.
        I actually think they would step up to the plate instantly
    if there was a little love on this side.
        Senator Shaheen. Mr. Chairman, I would suggest that we try
    to work with Reverend Warren as we are thinking about how we
    make sure we continue to fund the PEPFAR program.
        Senator Graham. Absolutely. What you are trying to do is
    consider how you brand this program in a positive way with the
    American taxpayers so they will understand the return on
    investment. I have been thinking about that a lot, and this
    panel helps. Senator Lankford.
        Senator Lankford. Thank you, and thank all of you for being
    here. Pastor Warren, let me finish out that conversation. Have
    you seen effective outreach from Government reaching out to the
    faith sector in any particular country that you have been to,
    that your church members have worked with, that you have seen
    that connection, whether it was with the United States
    Government or with other governments?
        Dr. Warren. I have actually found it quite easy to work
    with other governments.
        They are not nearly as afraid of the church as the American
    Government is. We work with governments literally all around
    the world. They are very friendly because they realize we are
    not trying to do their work. Everybody has a different role to
    play. The church's role is not government. The government's
    role is not church. On health issues and education issues and
    development issues, you can team tackle.
        As I said, I have just found it easier to work with
    governments overseas.
        Senator Lankford. It is ironic that we have distributed
    around the world this concept of freedom of religion and
    disconnect between government and faith, and to say that
    government does not oppose faith, but now like we are afraid of
    faith.
        It seems that is an obvious area of partnering when you
    talk about the number of hospitals, the number of clinics
    versus the number of churches, and I hear our experts on the
    medical side say one of the key things we have to have is a
    distribution center in that location, how do we get that.
        I think we cannot be afraid here of saying there is an
    obvious connection there, and where we can connect and where we
    can find good distribution and relationships, let's do. It
    seems to be one of our greatest challenges of getting to these
    areas with a relationship that is a trusted relationship to say
    this is a way to be able to deal with this disease or to be
    able to deal with this cultural issue, and let us engage with
    you in a relationship. I appreciate all that you are doing on
    this level.
        Let me shift a little bit. I am a little concerned, and
    this is one of the things that we deal with all the time, deal
    with on the funding side of what we are doing on this.
        The Global Fund received $1.3 billion in fiscal year 2015.
    We have $4.3 billion for the State Department's HIV/AIDS
    program, $330 million for USAID for HIV/AIDS programs, $128
    million for HHS' HIV and AIDS programs through the CDC, and
    $451 billion for NIH global research.
        My question is how are we doing on coordination? How is
    everyone doing talking to each other to make sure that everyone
    does not raise their hand and say there is a problem and we all
    agree there is a massive problem? How is the coordination of
    those dollars going? Is everyone doing their job or do we see
    duplication?
        Anyone who wants to jump into that, have at it.
        Ambassador Birx. Mark and I can answer that together. It is
    interesting how you put it together and thank you for framing
    it that way because you talked about our boss, we both were in
    Dr. Tony Fauci's lab at one time, and how we work with both the
    NIH and The Global Fund, and how we leverage resources.
        We work very closely obviously with NIH. They both support
    scientific development and capacity development in Africa with
    us, as well as key research that we need, and they thank
    goodness are working on an HIV vaccine and have a meeting this
    week on that, and we are very excited about the progress they
    are making.
        I think what was missing is the level of absolute working
    together at The Global Fund. Over the last 18 months, that has
    really transformed into an almost daily texting, unfortunately
    for Mark. We are in constant communication but we are in
    constant communication at every level within The Global Fund.
        Senator Lankford. How did that happen?
        Ambassador Birx. We just committed to it.
        Dr. Dybul. In part, perhaps because I was at PEPFAR in the
    beginning and Deb was there soon after, part of it is
    relationship, but part of it is just an evolution globally and
    in country. We have no in country presence. We are a financing
    mechanism. We are a leveraging mechanism to ensure that people
    will come together to finance.
        We raise money. For the $1.35 billion you put in, we spend
    $4 billion a year on HIV, TB, and malaria, and we raise it from
    all sectors. I have to say to the chairman's comments, without
    that leadership from the U.S., it will unravel. It is really
    the U.S. that does it.
        Then when we get to the country level, we work as a
    partnership. We bring also the multilateral partners, the U.N.
    institutions, other donors who have in country expertise to
    work collectively. The faith community in countries, the
    private sector in countries. We have forced ourselves together
    for impact and to get you value for money because we cannot
    achieve it any other way.
        Senator Lankford. Right. There are the obvious issues here
    and I want to keep pressing on this because we deal so much
    with the finance side. When we did the emergency funding for
    Ebola, $2.7 billion, we sent 3,000 folks to that area to build
    11 different Ebola centers, and if I remember my number
    correctly, we had 28 people that we ended up treating, with
    $2.7 billion. Uncoordinated, too late, massive response,
    delayed.
        We cannot have that in a disease like AIDS, we have to have
    coordination, interaction, and make sure every dollar is spent
    wisely. Should we have responded to Ebola? Yes. Did we do it in
    the most efficient way? I think time is going to tell us no, we
    did not do it in the most efficient way.
        I want to come back on that again. Is there a structure in
    place, and I am proud of the two of you, let me state it that
    way, that you are working on making sure there is lots of
    communication, but is there a structure in place to make sure
    this is ongoing? I hope that you all stay at it and that you
    work yourselves out of a job soon, quite frankly. That would be
    terrific news. How is it going, building the structure to make
    sure that is maintained?
        Ambassador Birx. There is a structure now at every level. I
    think part of it has to do with leadership and sending that
    signal very clearly down to every level that we will work
    together and we will work together not only in concert at the
    headquarters level and at the implementation level, but at the
    principal recipient level, that The Global Fund's money go
    through a principal recipient.
        It makes the principal recipients sometimes nervous how
    close our dialogue is about what precisely is The Global Fund
    doing and what precisely PEPFAR is doing. We can line that up
    and marry that information in an absolute clear and transparent
    way.
        That is what is new. It is what the Reverend talked about,
    data and data collection and transparency. That is what will
    ensure that there is not duplication because we now know down
    to the site level where his dollars are going and where our
    dollars are going.
        Senator Lankford. Thank you. Keep going on that. You all
    are doing some great work on raising funds and raising
    awareness and staying engaged in this, and we appreciate it,
    and we will continue to partner and try to help in what we can
    do as well. Thank you.
        Senator Graham. Thank you. That was an excellent line of
    inquiry that we will follow up on. Senator Merkley.
        Senator Merkley. Thank you, Mr. Chairman, and thank you for
    your leadership on this issue, this world challenge.
        There is a modest group of leaders who have had an impact
    on millions of lives. Mr. Chairman, you are one of those
    leaders and all of you on the panel, you are a part of that
    group, and huge thanks to you.
        I can think of some others who have been part of this
    conversation. Paul Farmer, who definitely laid out there are
    three pandemics in the world, tuberculosis, malaria, and AIDS,
    and we must take them on. That is kind of the biggest leverage
    we could have. Bono, who took Paul O'Neill over to Africa in
    2002 to connect on economic development and on the need to
    address AIDS.
        You all are absolutely marvelous. Sir Elton John, as you
    spoke, you spoke in poetic terms of compassion, love, and
    connection.
        I was really struck and taken to think about the good
    Samaritan story in how the individual goes on the road from
    Jerusalem to Jericho, which was known as the ``Blood Road''
    because it was so common for people to be robbed and beaten
    there. The priest comes by and sees the individual who has been
    robbed and stripped and beaten and left for dead and keeps
    going. The Levi comes by, the same thing.
        The Samaritan, and we have kind of forgotten this in modern
    terms, but the Samaritan, the Samaritans and the Jews were at
    odds with each other, deeply hostile to each other, but it was
    the Samaritan who stopped and helped out.
        The lawyer who was questioning Jesus proceeds to say who is
    your neighbor, and this is why he told this story, recognizing
    the one that reached out and had compassion and got involved
    when others did not, and you all have done that. I thank you so
    much.
        The piece of this puzzle that I would like to ask you to
    add some additional comments on is this challenge of stigma.
    Back in the 1970s, Mrs. Ford, First Lady Ford, proceeded after
    her mastectomy to talk about breast cancer in a way that opened
    the conversation in America for something that was really kind
    of hidden and was not talked about and was not explored.
        In your work, I am sure you have connected with certain
    leaders who have changed that dynamic of stigma in different
    countries or among different groups. Can you give us some
    examples of the type of path they have gone down that we should
    try to find ways to encourage others to follow?
        Sir Elton. It is very important, as you stress, for people
    to come out and talk about these challenges. When Mrs. Ford
    said that she had a mastectomy, it helped so many women.
        When Magic Johnson said he had HIV, it created an
    incredible opportunity to educate the public. It was very early
    on in the pandemic. Similarly, when Arthur Ashe was diagnosed.
    When people come out, even if they are gay, transgender,
    whatever, people who are out there feeling alone and suffering
    in silence, they realize that they are not alone. There are
    others in their situation. When someone they can identify with
    comes out and says listen, I have this and it is okay, it is an
    incredibly powerful experience. It is a necessity. Not enough
    people who have HIV who are well known have come out and said I
    am HIV positive.
        That saddens me. It would help so much if more role models
    and more famous people, more sportsmen were open. In Africa, as
    in most places, they love sports. Their heroes are sportsmen.
    There are many, many people in this world who are HIV positive
    and are famous and are too scared to come out and say it.
        It would help if they did. Coming to terms with living with
    HIV would be so much easier. Stigma could be lifted if only
    more people would come out and say listen, I am living with
    this disease, I have HIV or AIDS, I am not dying, I am living
    with it. That would help in many circumstances.
        Look at Angelina Jolie. She has had a double mastectomy,
    she said I do not want to have the cancer that my mother had.
    She took action and she talked about it publicly to raise
    awareness. It all helps. People look up to famous people, God
    knows why sometimes, but they do, and especially with AIDS, it
    is very, very important for more people to say listen, I am HIV
    positive, I am living with it. You do not have to be ashamed.
        Because it is a sexually transmitted disease, I think its
    even harder for people to talk about. You come back from the
    doctor and say I have a terrible cough or a stomachache, you do
    not come back and go to lunch with a friend and say I have just
    come from the doctor, I have AIDS.
        There is no reason why you should not, it is just because
    there is stigma, because it is a sexually transmitted disease
    or a disease of sharing needles. If more people came out and
    more famous people came out and said listen, I live with it, it
    is okay, then it would make our situation so much easier.
        Senator Merkley. If we extend that conversation to nations
    where the conversation is far more oppressed or underground
    than it is here, and Dr. Warren, you had indicated you might
    have something to add to this and I would love to hear your
    thoughts, but are there some spiritual leaders, some
    governmental leaders, some medical leaders who have taken bold
    stands and helped change the course of policy and dialogue in
    countries that we could try to encourage in other places?
        Dr. Warren. Whenever I find a pastor who has AIDS, I tell
    him you have to tell everybody, it may be the greatest thing
    you do with your life. People do not realize, we actually help
    people more out of our weakness than out of our strengths.
        If I tell you all the things I am good at, you say goody
    for you. If I tell you things that I am struggling with, then
    you go oh, maybe God could work in my life, too, in spite of
    all that.
        Most people know that 18 months ago, my youngest son who
    struggled with mental illness for some 27 years took his life.
    It was the worst day of my life. Kay and I decided we would be
    obviously open about it. I went on CNN. We spent an hour giving
    testimony to Piers Morgan on that. It opened the floodgate.
    Why? Because you do not help people with your strengths.
        I used to think AIDS was the biggest stigma. I do not any
    more. I actually think mental illness is a bigger stigma. More
    people are afraid of that. It is not a sin to be sick. Your
    illness is not your identity. Your chemistry is not your
    character.
        When leaders stand up and say I am struggling with this, a
    political leader, AIDS or anything else, it actually allows
    other people to make progress. We help people more through our
    weaknesses than our strengths.
        Sir Elton. May I please comment Senator?
        Senator Merkley. Please.
        Sir Elton. When I went to South Africa about 12 years ago,
    I saw so many women who had been widowed because their husbands
    had died of AIDS. I was sitting at the Baragwanath Hospital in
    Soweto at a round table with about 15 people. The women were
    wearing t-shirts that said ``HIV Positive.''
        That was the start of a movement where the women in South
    Africa took their power back. Rick absolutely hit the nail on
    the head. Our weaknesses are our strengths.
        From a personal point of view, I am terrible at asking for
    help. I would rather suffer in silence than say can you please
    help me with this. But it is okay to be human. It is okay to
    have made a mistake. It is okay to have a weakness or be
    vulnerable. He hit the nail right on the head, our weaknesses
    are our strengths.
        When you empower somebody by saying listen, I am not as
    strong as you think I am, it helps a lot. It really does.
        Senator Merkley. Thank you all so very much, and that
    example shows the powers of grassroots action, that it is not
    just about leaders who help drive policy or change but citizens
    together standing up and saying we are changing how this is
    done. Thank you.
        Senator Graham. Senator Murphy.
        Senator Murphy. Thank you very much, Mr. Chairman. What an
    impressive panel with fantastic testimony.
        Dr. Warren, let me just thank you for raising the issue of
    mental illness. This is not something we tend to talk about in
    global terms. We tend to talk about communicable diseases
    primarily. The reality is the stigma is not domestic, it is
    international.
        The good news here on this issue is hopefully there is a
    little bit more bipartisan agreement, myself and Senator
    Cassidy and others are working on a major rewrite of the Health
    Insurance Portability and Accountability Act (HIPAA) health
    laws, but we need to think about this globally as well, and
    hopefully it becomes part of the conversation.
        Senator Lankford had an interesting line of testimony and
    inquiry. One of the things he talked about was the response to
    Ebola. I do not want people to get the impression that the only
    thing we did was build a whole bunch of facilities. We did
    that, and in part because there were estimates there were going
    to be a million cases by early this year, so we had to be ready
    for the worse case.
        We also put a lot of work into our local partners,
    everything from the right ways to quarantine to the safe
    practices for those that perished from the disease, and it was
    a lot of that work that made an enormous amount of progress.
        I want to ask about this question of how we work with local
    governments to improve governance, to improve their local
    public health systems so that ultimately we are not just
    relying on the generosity of the United States and the church
    community, the international communities.
        The reality is global surveys suggest that one out of every
    five people in this world have actively paid abroad to get
    health service and 40 percent of people view their health care
    system as utterly corrupt. We know where those survey results
    are even higher.
        How do our public health officials--I will ask Dr. Dybul
    this first, how do we make sure our public health dollars are
    intersecting with the other pots of money that we use to
    improve governance, and are we doing that in the right way and
    with the right level of coordination today?
        Dr. Dybul. Thank you, Senator. I think the most important
    word is the last one, ``today,'' because I do not think we were
    there five to 7 years ago, and we have a way to go, but the
    progress has been extraordinary in how we do this.
        The way The Global Fund functions is we fund many
    governments directly, and that actually has brought an enormous
    amount of accountability. PEPFAR does as well.
        I will never forget President Kagame in Rwanda said this is
    the first time someone has held us accountable. In the past, we
    gave money and measured it based on how much money we gave.
    Now, it is results. You have to report results down to the site
    level. We are investing heavily in data and data management
    systems.
        It is really hard to steal money if you have to show
    results. It is much easier if you can just say I did some
    things. It is drilling down that accountability and data
    reporting down to the site level.
        Then we have layers and layers of investigative approaches
    that look at how every dollar is used. The reality is sometimes
    it does go in the wrong place, but we find it collectively, and
    then we bring people to justice. People are actually going to
    jail now for the first time for corruption in the health system
    in many countries around the world. It is actually really
    exciting to see.
        This is something that we do not talk about much; these
    health programs have actually driven accountability in a way
    that really never existed before.
        Senator Murphy. We should really care about corruption when
    our dollars are on the ground, but we should frankly care just
    as much when our dollars are not on the ground because we would
    not need to use as much money if the systems are efficiently
    run.
        In those cases, who is the right government entity to try
    to build that capacity? Is it our global health dollars or
    should those be reserved for running programs, or is it other
    pieces of the State Department who are more in the business of
    working with governments at large to make them more
    accountable, more efficient, and less corrupt?
        Ambassador Birx. The great thing about what Dr. Dybul just
    talked about is how that is integrated at the site by the State
    Department and the Chief of Missions. The U.S. Government has
    Ambassadors in each of these countries. It is valuable to get
    him or her data that reflects the quality of the work at the
    site, the cost of delivering those services, and then
    integrates them in a three way analysis, comparing all the
    other sites and all the other partners.
        You can clearly then see what sites are out of range
    because they are doing more work with less dollars and high
    quality, and which sites are out of range because it is costing
    more for a low quality product.
        Then we send people in to actually go to those sites and
    define each of those issues, and then the Ambassador takes it
    forward. We are doing this in partnership with The Global Fund
    starting out in the countries where we share impact, in about
    40 countries, and then that same system can be taken into
    countries where the U.S. Government is providing still a third
    of the dollars through The Global Fund where there may not be a
    PEPFAR program.
        Senator Murphy. Dr. Warren, you were a little optimistic on
    your ability to work with local governments. That is not always
    the story that we hear. How much does it matter whether you
    have a local governance structure that is efficient, relatively
    low on the corruption scale?
        I would imagine you look very carefully at those factors
    when you are thinking about where to put your dollars and your
    programming.
        Dr. Warren. Yes, that is why I go back to this holistic
    approach to aid and assistance. In the P.E.A.C.E. Plan, promote
    reconciliation, equip certain leaders or ethical leaders,
    because we believe corruption is one of the big five problems
    in the world, along with poverty, disease, illiteracy, and
    conflict.
        You have to deal with all of them at the same time. You
    cannot just deal with poverty. You have to deal with
    corruption. You cannot just deal with corruption, you have to
    deal with education. You have to deal with all these together.
        I found in working with local governments around the world
    the most important thing first is to just listen, to not assume
    I know what I know about the country. When I go into a country,
    the first thing I do is just take a yellow clipboard and sit
    down and listen, listen to their culture, listen to their
    values. I am listening to what they are saying. I am not coming
    in and automatically imposing something because I want to find
    out what do you need.
        There is a verse in the Bible that says when you go in the
    village, find the man of peace, which is why we named it the
    P.E.A.C.E. Plan. The peace person in any culture or in any
    corporation, I have found them in nations, I have found them in
    businesses, you find the man of peace, they are influential and
    open to work with you.
        By the way, they do not have to be a Christian, because
    when Jesus told them to go find the man of peace, there were
    not any Christians yet. He had not died on the cross. He said
    go find the man of peace.
        I found men of peace who were Muslims, who were atheists,
    who were straight, who were gay. They are willing to work with
    you and they are influential. If you find those kinds of
    people, then you start with the man of peace, and you can begin
    to expand.
        I think it starts with listening.
        Senator Murphy. I think that is a wonderful way to think
    about this. I guess one of the points I am trying to make here,
    Mr. Chairman, is when we look at the money that we spend and
    the benefit that is accrued to global health, we should not
    just look at the accounts that are labeled ``global health.''
        When you are running programs that build men of peace, that
    promote their ability to have influence, whether or not that is
    a health line item or not, that actually builds better local
    health systems.
        As we are reviewing the budget at large, just as important
    to pay attention to the fact that sometimes the titles in the
    line items do not necessarily translate their benefit. Thank
    you, Mr. Chairman.
        Senator Graham. Thank you. Thank you all for participating
    in the hearing. I think each in your own way have tremendously
    advanced the cause for protecting global health programs, which
    I am completely dedicated to because I can just see how close
    we are, and the damage that could be done if we back off now.
        In a news cycle full of bad news most of the time, maybe we
    will get five seconds of good news from what you have had to
    say here today.
        One thing I have learned is if we get any extra money, we
    will go into the data collection business.
        To all of you, God bless. You represent the best not only
    in our country but the best in mankind. You will have a friend
    in this committee.

                         ADDITIONAL COMMITTEE QUESTIONS

        We will keep the record open for questions until the close
    of business on Friday, May 15.
        [The following questions were not asked at the hearing, but
    were submitted to the organization for response subsequent to
    the hearing:]
                     Questions Submitted to Dr. Mark Dybul
                Questions Submitted by Senator Patrick J. Leahy
        Question. Ambassador Dybul, U.S. law limits U.S. contributions to
    the Global Fund to 33 percent of total contributions by all
    governments. Over the past several years the U.S. contribution has
    decreased due to lower contributions from other governments.
        What accounts for the shortfall in contributions from other donors,
    how has it impacted the Global Fund's programs, and do you have any
    reason to think that other donors will increase their contributions?
        Answer. Much of the world has been struggling with a prolonged
    financial crisis that threatens to undermine or even reverse key gains
    in global health that have been achieved to date. Countries which were
    most severely affected by the financial crisis in 2010 implemented deep
    budget cuts and austerity measures and curtailed their flows of
    development aid. Italy and Spain, which were the Global Fund's 8th and
    9th largest donors and made annual contributions of $130 million and
    $200 million, stopped all contributions starting in 2010, as did
    Ireland, Iceland and Portugal. Contributions from the United States and
    Canada, whose economies better weathered the crisis continued to rise,
    as did those of the United Kingdom, in spite of the imposition of
    budget cuts and domestic austerity measures.
        Despite the challenging global financial situation, in December
    2013 at the Global Fund 4th replenishment meeting hosted by President
    Obama, donor contributions increased by more than 30 percent from the
    previous replenishment period from a total of $9.2 billion announced at
    the 3rd replenishment launch in 2010 to $12 billion announced in
    December 2013. The Global Fund stepped up its engagement and advocacy
    with countries recovering from the financial crisis and as their
    economies gradually improved, donors such as Italy, Ireland and
    Portugal renewed their contributions to the Global Fund albeit at much
    lower levels. The United States continues to be the Global Fund's
    largest donor and it is on track to slightly increase the level of
    contribution it established in the 3rd replenishment period--U.S. $4
    billion from 2011 to 2013, to U.S. $4.1 billion during the 4th
    replenishment period, encompassing 2014 to 2016.
        The Global Fund is actively working on widening its donor base by
    approaching the governments of emerging economies, the private sector
    and high-net worth individuals. The private sector in particular has
    been a strong and growing partner for the Global Fund which through
    direct contributions has invested $1.7 billion to date. Private
    corporations' and high net worth individuals' donations to the Global
    Fund have increased by more than 50 percent since 2010. The growing
    involvement of high-net-worth individuals from countries receiving
    Global Fund financing is opening new exciting opportunities to channel
    resources in innovative ways. High-net-worth-individuals from India,
    Indonesia, South Africa and Vietnam have made commitments to the Global
    Fund of more than $100 million.
        To improve country ownership and sustainability of supported
    programs, the Global Fund implements counterpart financing policies for
    domestic funding support to the three diseases and the health sector.
    To further incentivize additional government investments in health, the
    current funding model also incorporates a `` `willingness to pay'
    requirement'' to access the full allocation. Submissions for the first
    five waves resulted in national governments committing an additional
    U.S. $4.1 billion for 2015-2017. Compared with spending in 2012-2014,
    this represents a 52 percent increase in domestic financing.
        Question. Before this job you had Dr. Birx's job. How would you
    describe PEPFAR's impact in helping to build public health capacity not
    only to address HIV/AIDS but other health threats in focus countries?
        Answer. PEPFAR recognizes, as does the Global Fund, the importance
    of health systems strengthening (HSS), both to improve access to and
    quality of healthcare, and to ensure sustainability of the gains
    achieved against the epidemics of HIV/AIDS, tuberculosis and malaria. A
    health system encompasses the individuals, organizations and processes
    focused on ensuring health outcomes.
        From very early on, PEPFAR has made sure the strategic planning and
    implementation of its prevention, care, and treatment activities
    carefully takes in consideration their impact on partner country health
    systems. Its broad global investments in HIV/AIDS, have made resources
    available that have contributed to the improvement of health systems,
    with impacts, for example, on maternal, newborn and child health.
        PEPFAR funding and technical assistance has had a positive impact
    on the capacity of recipient countries to improve the six core building
    blocks of health systems functions: service delivery; human resources
    for health; medical products, vaccines and technologies; information;
    governance; and finance.

                             CONCLUSION OF HEARINGS

        This committee stands in recess subject to the call of the
    Chair.
        [Whereupon, at 12:06 p.m., Wednesday, May 6, the hearings
    were concluded, and the subcommittee was recessed, to reconvene
    subject to the call of the Chair.]