[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.]