    [Senate Hearing 118-53]
    [From the U.S. Government Publishing Office]

                                                             S. Hrg. 118-53

                          PEPFAR AT 20: ACHIEVING AND
                          SUSTAINING EPIDEMIC CONTROL

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON FOREIGN RELATIONS
                              UNITED STATES SENATE

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 FIRST SESSION
                                   __________

                                 APRIL 19, 2023
                                   __________

           Printed for the use of the Committee on Foreign Relations

                      [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                      Available via http://www.govinfo.gov
                                   __________

                        U.S. GOVERNMENT PUBLISHING OFFICE

    52-968 PDF               WASHINGTON : 2023

                     COMMITTEE ON FOREIGN RELATIONS

                 ROBERT MENENDEZ, New Jersey, Chairman
    BENJAMIN L. CARDIN, Maryland           JAMES E. RISCH, Idaho
    JEANNE SHAHEEN, New Hampshire          MARCO RUBIO, Florida
    CHRISTOPHER A. COONS, Delaware         MITT ROMNEY, Utah
    CHRISTOPHER MURPHY, Connecticut        PETE RICKETTS, Nebraska
    TIM KAINE, Virginia                    RAND PAUL, Kentucky
    JEFF MERKLEY, Oregon                   TODD YOUNG, Indiana
    CORY A. BOOKER, New Jersey             JOHN BARRASSO, Wyoming
    BRIAN SCHATZ, Hawaii                   TED CRUZ, Texas
    CHRIS VAN HOLLEN, Maryland             BILL HAGERTY, Tennessee
    TAMMY DUCKWORTH, Illinois              TIM SCOTT, South Carolina
                    Damian Murphy, Staff Director
           Christopher M. Socha, Republican Staff Director
                       John Dutton, Chief Clerk

                                  (ii)

                          C  O  N  T  E  N  T  S

                                  ----------
                                                                       Page

    Menendez, Hon. Robert, U.S. Senator From New Jersey..............     1

    Risch, Hon. James E., U.S. Senator From Idaho....................     3

    Nkengasong, Hon. John N., Ph.D., U.S. Global Aids Coordinator,
      U.S. Special Representative for Global Health Diplomacy, United
      States Department of State, Washington, DC.....................     4
        Prepared Statement...........................................     6

    John, Sir Elton, Founder, Elton John Aids Foundation, London,
      United
      Kingdom........................................................    18
        Prepared Statement...........................................    20

    Dybul, Hon. Mark, M.D., Professor of Medicine and Chief Strategy
      Officer, Georgetown University Medical Center for Global Health
      Practice and
      Impact.........................................................    22
        Prepared Statement...........................................    24

                  Additional Material Submitted for the Record

    Testimony of Dr. Eric Goosby and Dr. Richard Marlink.............    25

    Responses of Dr. John Nkengasong to Questions Submitted by
      Senator Bill Hagerty...........................................    38

    Statement From David J. Kramer, George W. Bush Institute, Dated
      April 19, 2023.................................................    41

                                     (iii)

                          PEPFAR AT 20: ACHIEVING AND
                          SUSTAINING EPIDEMIC CONTROL

                                  ----------

                           WEDNESDAY, APRIL 19, 2023

                                           U.S. Senate,
                                Committee on Foreign Relations,
                                                        Washington, DC.
        The committee met, pursuant to notice, at 10:03 a.m., in
    room SD-419, Dirksen Senate Office Building, Hon. Robert
    Menendez presiding.
        Present: Senators Menendez [presiding], Cardin, Coons,
    Kaine, Booker, Van Hollen, Risch, Young, Barrasso, and
    Ricketts.

              OPENING STATEMENT OF HON. ROBERT MENENDEZ,
                      U.S. SENATOR FROM NEW JERSEY

        The Chairman. This hearing of the Senate Foreign Relations
    Committee will come to order.
        To speak about ending the scourge of HIV/AIDS is to speak
    of a miracle. When the President's Emergency Plan for AIDS
    Relief was established in 2003, for most people around the
    world an HIV/AIDS diagnosis was a death sentence, but 20 years
    later, through the generosity of the American people and one of
    the most successful foreign assistance programs in history, we
    have changed the course of human history.
        We have given millions of people access to lifesaving
    treatment and today's hearing comes at a critical time as we
    prepare to reauthorize the President's Emergency Plan for AIDS
    Relief, or PEPFAR as it is known.
        This next 5 years will determine whether we meet the goal
    of ending the global HIV/AIDS epidemic by 2030. We must not
    take our foot off the accelerator if we hope to be successful.
        I would like to thank our witnesses, Dr. John Nkengasong,
    Sir Elton John, and Professor Mark Dybul for appearing before
    us today. I look forward to your frank assessment of the state
    of HIV/AIDS epidemic, your thoughts on what the United States
    and our partners in the international community can do to
    achieve the goal of ending this epidemic by 2030 because, as
    you know, major challenges still remain.
        It is not just that COVID-19 slowed access to HIV services.
    New infections are not declining as fast as we would like.
    There are more and more cases among Africa's surging young
    populations with young women and adolescent girls twice as
    likely to be affected--infected, I should say--as young men.
        Children, the most vulnerable population, continue to be at
    the highest risk. According to UNAIDS, at the end of 2021, 76
    percent of adults living with HIV were assessing treatment
    compared to only 52 percent of children.
        We have also seen a disturbing trend towards criminalizing
    key high-risk populations like Uganda's recently approved anti-
    homosexuality act of 2023. These laws drive vulnerable
    communities underground, keeping them from accessing testing,
    prevention technologies, and essential medicines, all of which
    increases the number of infections and undermines years of
    investment.
        We cannot eradicate this epidemic if we leave communities
    behind nor can we sustain the progress that has already been
    made unless our partners fulfill their commitments.
        During the Abuja Summit in 2001, African leaders pledged 15
    percent of their budgets for health. Today, only three
    countries are honoring that commitment.
        Of course, while we cannot achieve our goals without
    support from heads of state in PEPFAR countries, the United
    States must continue to show leadership at this crucial time.
        Our country has not overcome our greatest challenges by
    taking them on half-heartedly. When it comes to defeating one
    of the most devastating epidemics we have ever seen, we need to
    make sure our investments in PEPFAR have the greatest impact
    possible.
        That means ensuring that PEPFAR activities strategically
    strengthen health systems to improve overall health security,
    including at the community level. It means doubling down on
    building secure supply chains, on training health workers, on
    building lab capacity, and on the ability of partner countries
    to prevent, detect, and respond to infectious diseases,
    especially those with pandemic potential.
        It also means tailoring our investments to reflect partner
    nations' priorities. If we do this right we not only lower
    costs and improve efficiencies in health systems across the
    board, we can end the AIDS epidemic as a public health threat
    by 2030.
        The gains we have already seen speak for themselves.
    Twenty-five million lives have been saved, 5.5 million babies
    have been born HIV-free in over 50 countries, and more than 20
    million people are on antiretroviral treatment.
        Since 2004 we have reduced the number of people being
    infected with HIV/AIDS across PEPFAR countries by 52 percent.
    PEPFAR has achieved far more beyond the disease itself than any
    one of us could have envisioned.
        We have seen declines in mortality, improvements in
    maternal and child health, more girls and boys staying in
    school, and more than 2 percent GDP gains in PEPFAR-supported
    countries.
        The initiative is a testament to what the Congress and the
    executive branch can do and we agree to lead collective action
    to address global challenges.
        Today, as we stand on the brink of an even greater
    achievement, the end of the epidemic, we cannot and should not
    turn back. Success is within our grasp.
        I look forward to hearing from our witnesses about how we
    cross the finish line. It is the chair's intention to get this
    legislation reauthorized. We look forward to working with the
    ranking member on this.
        With that, we turn to the ranking member for his opening
    statement.

                   STATEMENT OF HON. JAMES E. RISCH,
                        U.S. SENATOR FROM IDAHO

        Senator Risch. Thank you very much, Mr. Chairman. Despite
    which party controls Congress, the White House, over the last
    20 years the bipartisan coalition that supports PEPFAR remains
    strong.
        That is because the basic principles of effective
    resourcefulness, transparency, accountability, and results were
    part of PEPFAR's DNA from the very beginning.
        Also, through PEPFAR we have helped transform health
    systems and build foundations for broader health security,
    including for pandemic preparedness, but more than anything, I
    believe support for PEPFAR remains strong because its success
    is measured in lives saved, and we have saved millions of
    lives.
        PEPFAR, clearly, is a model. That is why it served as the
    model for my recently enacted Global Health Security and
    International Pandemic Prevention, Preparedness and Response
    Act, but it is also an undeniable expression of the values and
    interests that make us uniquely American.
        This is a legacy which we can all be proud of. I urge my
    colleagues to join me in working to reauthorize PEPFAR without
    delay and without new mandates and directives.
        As our witnesses I am sure will testify, the coordinator
    already has the authorities required to ensure PEPFAR remains
    fit for purpose while preserving core U.S. values and advancing
    longstanding sustainability and self-reliance.
        This includes authority to direct funds set aside for
    orphans and vulnerable children, towards supporting adolescent
    girls who are the most vulnerable to new infections, as well as
    for closing gaps in pediatric treatment.
        It also includes authority to ensure that PEPFAR-supported
    maternal and child health activities deliver results by
    preventing mother-to-child transmission.
        The requirement to devote not less than half of the budget
    toward lifesaving treatment and care must be preserved, which
    is all the more appropriate now that treatment has become a
    proven form of prevention.
        Finally, we must extend the 33 percent cap on U.S.
    contributions to the Global Health Fight to AIDS, Tuberculosis
    and Malaria, which was put in place to ensure other donors were
    generously providing their fair share rather than expecting the
    United States to do it all.
        It also includes other withholding requirements relating to
    transparency and accountability at the fund. This is a
    reauthorization and we do not need to recreate the wheel. Also,
    we do not need to incorporate new directives relating to
    sustainability. We already did that back in 2013.
        Let us not bog down the process by wordsmithing what
    already exists. This program is too important for that.
    Instead, let us advance a clean reauthorization and get on with
    the business of rigorous oversight, including close scrutiny of
    PEPFAR's local implementing partners.
        I hope we can all agree and commit to advancing a timely,
    clean reauthorization of this values-based lifesaving program.
        Thank you, Mr. Chairman.
        Mr. Chairman, I would like to include for the record a
    statement from the George W. Bush Institute.
        The Chairman. Without objection, and thank you for your
    statement.

    [Editor's note.--The information referred to above can be found
    in the ``Additional Material Submitted for the Record'' section
    at the end of this hearing.]

        The Chairman. Let us turn to our first panel.
        With us on behalf of the Administration is Dr. John
    Nkengasong, who serves as the U.S. Global AIDS Coordinator
    Special Representative for global health diplomacy.
        In his role, Dr. Nkengasong leads, manages, and oversees
    the U.S. President's Emergency Plan for AIDS Relief where he
    works to prevent millions of HIV infections, save lives, and
    make progress towards ending the HIV/AIDS pandemic.
        Prior to this role, Dr. Nkengasong was appointed as the
    first director of the Africa Centers for Disease Control and
    Prevention. During his tenure, he was also appointed as one of
    the World Health Organization's special envoys on COVID-19
    preparedness and response.
        He has also served in the division of global HIV and
    tuberculosis at the U.S. Centers for Disease Control and
    Prevention. It was good to join you in Africa in February, Dr.
    Nkengasong, where we saw firsthand some of the work that we are
    doing.
        We welcome you to the committee and please proceed with
    your testimony.

      STATEMENT OF THE HONORABLE JOHN N. NKENGASONG, PH.D., U.S.
    GLOBAL AIDS COORDINATOR, U.S. SPECIAL REPRESENTATIVE FOR GLOBAL
         HEALTH DIPLOMACY, UNITED STATES DEPARTMENT OF STATE,
                             WASHINGTON, DC

        Dr. Nkengasong. Thank you, Chairman Menendez, Ranking
    Member Risch, and other distinguished committee members. I am
    deeply honored to appear before the Senate Foreign Relations
    Committee, which has provided visionary leadership for PEPFAR
    since its inception in 2003.
        In the past 20 years PEPFAR has saved 25 million lives.
    PEPFAR has strengthened health systems and PEPFAR has changed
    because of HIV/AIDS pandemic. The American people should be
    proud of these remarkable achievements of their achievements.
        We all know that these gains are fragile and without
    continued leadership of this Congress, we risk reversing the
    gains with every surging of the HIV/AIDS pandemic.
        Back in 2003, HIV/AIDS was a death sentence and, for
    instance, in Africa, average life expectancy had dropped
    significantly by 35 years in Zimbabwe, 12 years in South
    Africa.
        This year we are celebrating the 20th anniversary of PEPFAR
    and it has been without doubt the greatest act of humanity in
    the history of fighting infectious diseases. Thanks to the
    generosity of the American people, PEPFAR's investments are
    supporting over 20 million people on lifesaving treatments and
    have prevented HIV infections in 5.5 million babies.
        PEPFAR has also played a key role in transforming
    societies. For example, in PEPFAR-supported countries GDP per
    capita has grown two percentage points faster, and girls and
    boys are nine percentage points more likely to be in school.
        The previously unthinkable goal of ending HIV/AIDS as a
    public health threat is now within our grasp, all due to the
    unwavering commitment of the members of this committee and the
    bipartisan bicameral support of 10 Congresses and four
    administrations.
        Our focus is on the goal of ending HIV/AIDS pandemic by
    2030. On December 1, World AIDS Day, we released a 5-year
    strategy that provides a plan for how to get there and I want
    to share a few highlights.
        One key area of focus is health equity. There are still 1.5
    million new HIV infections globally and over 650,000 AIDS-
    related deaths each year. A disproportionate number of these
    are in three categories: adolescent girls and young women,
    children, and five key populations. We must continue to know
    our gaps and close our gaps.
        To lead with data and follow the science, we must align our
    programs to locations and populations where HIV/AIDS is the
    most concentrated. We will work with affected communities,
    partner governments, the private sector, and civil society
    partners to ensure the dignity of all people.
        Another key area of focus is sustaining the response. HIV
    is a lifelong disease and our partner countries will be
    responsible for supporting millions of people on treatment for
    the remainder of their lives.
        For the first time in PEPFAR's history I had the honor of
    addressing a special session of 33 heads of states at African
    Union's summit in February.
        That session resulted in a declaration that the head of
    states will host a dedicated summit later this year to develop
    a roadmap of action and investment through 2030. As PEPFAR we
    work hand-in-hand with partner country governments to advance
    these commitments.
        Mr. Chairman and all members of this distinguished
    committee, what once was unimaginable is now very possible.
    That is ending HIV/AIDS as a public health threat by the year
    2030.
        Yet, our gains are incredibly fragile. If a person living
    with HIV does not have access to medication for just 3 weeks
    their viral load will increase and they will be a risk for
    transmission and developing AIDS.
        With your leadership we can protect our gains and reach the
    2030 goals. That is why I look forward to working with this
    committee to reauthorize PEPFAR. Thank you for the ongoing
    support for PEPFAR's work and I look forward to your questions.
        [The prepared statement of Mr. Nkengasong follows:]

                   Prepared Statement of Dr. John Nkengasong

        Thank you, Chairman Menendez, Ranking Member Risch, and other
    distinguished Committee members. I am deeply honored to appear before
    the Senate Foreign Relations Committee, which has provided visionary
    leadership for PEPFAR since its inception in 2003.
        In the last 20 years, PEPFAR has saved 25 million lives, PEPFAR has
    strengthened health systems, and PEPFAR has changed the course of the
    HIV/AIDS pandemic. The American people should be proud of these
    remarkable achievements as they are their achievements. We all know
    that these gains are fragile and without continued leadership of this
    Congress, we risk reversing the gains with a resurgence of the HIV/AIDS
    pandemic.
        Back in 2003, HIV/AIDS was a death sentence and for instance in
    Africa, average life expectancy had dropped significantly by 35 years
    in Zimbabwe and 12 years in South Africa.
        This year, we are celebrating the 20th anniversary of PEPFAR--and
    it has been, without a doubt the greatest act of humanity in the
    history of infectious disease. Thanks to the generosity of the American
    people, PEPFAR's investments are supporting over 20 million people on
    lifesaving treatment and have prevented HIV infections in 5.5 million
    babies.
        PEPFAR has also played a key role in transforming societies. For
    example, in PEPFAR-supported countries, GDP per capita has grown 2
    percentage points faster, girls and boys are 9 percentage points more
    likely to be in school.
        The previously unthinkable goal of ending HIV/AIDS as a public
    health threat is now within our grasp, all due to the unwavering
    commitment of the members of this Committee and the bipartisan,
    bicameral support of 10 Congresses and four Administrations.
        Our focus is on the goal of ending the HIV/AIDS pandemic by 2030.
    On December 1, World AIDS Day we released a 5-year strategy that
    provides a plan for how to get there and I want to share a few
    highlights.
        One key area of focus is health equity. There are still 1.5 million
    new HIV infections globally and over 650,000 AIDS-related deaths each
    year. A disproportionate number of those are in three categories--(1)
    adolescent girls and young women, (2) children, and (3) the five key
    populations. We must continue to know our gaps and close our gaps.
        To lead with data and follow the science, we must align our
    programs to locations and populations where HIV/AIDS is the most
    concentrated. We will work with affected communities, partner
    governments, the private sector and civil society partners to ensure
    the dignity of all people.
        Another key area of focus is sustaining the response. HIV is a
    lifelong disease, and our partner countries will be responsible for
    supporting millions of people on treatment for the remainder of their
    lives.
        For the first time in PEPFAR's history, I had the honor of
    addressing a special session of 33 Heads of State at the African Union
    Summit this February. That session resulted in a declaration that the
    Heads of State will host a dedicated summit later this year to develop
    a roadmap of actions and investments to 2030. As PEPFAR, we work hand-
    in-hand with partner country governments to advance these commitments.
        Mr. Chairman and all members of this distinguished Committee, what
    once was unimaginable is now very possible--ending HIV/AIDS as a public
    health threat by 2030. Yet our gains are incredibly fragile. If a
    person living with HIV does not have access to medication for just 3
    weeks, their viral load will increase and they will be at risk for
    transmission and developing AIDS. With your leadership, we can protect
    our gains and reach the 2030 goal.
        That is why I look forward to working with this committee to
    reauthorize PEPFAR. Thank you for the ongoing support for PEPFAR's
    work. I look forward to your questions.

        The Chairman. Thank you, Dr. Nkengasong. Maybe you could do
    a little seminar for your colleagues at the Department of
    State. You did not use your full 5 minutes. It is welcome so
    that you gave us some time back.
        Let me start off--we will start a round of 5-minute
    questions, and let me just say for the record there are a
    series of our colleagues who are very interested in this
    subject matter, but unfortunately there is a hearing at the
    same time before the Foreign Operations Appropriations
    Committee with Samantha Power and so both the chairman, Senator
    Coons and Senators Shaheen, Murphy, and Schatz have all of
    their members there.
        I just want to express that they are very interested in
    reauthorization and could not be here because of that conflict.
        Ambassador, our respective staffs have engaged as we work
    towards reauthorization. I understand your office has provided
    data related to the earmarks on care and treatment in orphans
    and vulnerable children that already currently reside in the
    PEPFAR statute.
        Can you say with 100 percent certainty that in the next 5
    years you will not need to pursue a waiver for earmarks
    currently in law through the appropriations process? If you are
    not 100 percent sure, what steps do we need to take to the
    reauthorization process to ensure you have the tools and the
    flexibility that you need?
        Dr. Nkengasong. Thank you. Thank you, Mr. Chairman.
        Absolutely certain that in 5 years, currently. The current
    authorities that we have has enabled us to get this far and we
    believe that----
        The Chairman. Is your microphone on? I am sorry.
        Dr. Nkengasong. Oh. Excuse me.
        Mr. Chairman, I can absolutely state that we do not need
    any additional authority. The current authority that we have
    will enable us to continue to respond appropriately as we have
    done over the last 20 years.
        The Chairman. Okay. Can I have your commitment that our
    staffs can meet within the next week to discuss further the
    data that you provided to the committee, which has led to the
    conclusion that earmarks will not need to be adjusted before
    2028?
        Dr. Nkengasong. We would certainly continue to work with
    your staff as we have done previously, Mr. Chairman.
        The Chairman. Now, one of the issues your office has
    identified as a challenge to ending AIDS by 2030 is that PEPFAR
    needs to reach the vulnerable 24- to 35-year-old cohort. Young
    women and adolescent girls in sub-Saharan Africa remain
    disproportionately vulnerable to infection.
        If we do not break that cycle, I fear that the decline in
    new infection rates will continue to slow and may stagnate,
    preventing countries from reaching epidemic control.
        The DREAMS program--Determined, Resilient, Empowered, AIDS
    Free, Mentored, and Safe--targets young women ages 15-24 and
    has proven quite effective in providing young women with the
    tools to prevent infection.
        My question is how are you reaching women aged 24-35 with
    targeted interventions to reduce their vulnerability? What
    about men in that age cohort?
        Dr. Nkengasong. Thank you, Mr. Chairman.
        As you already said that--the age group 24-35 is extremely
    concerning, especially adolescent girls and young women. Our
    statistics from UNAIDS indicate that adolescent girls and young
    women in that age group are 14 times more vulnerable than the
    corresponding males in that category.
        We have continued to develop a comprehensive prevention
    program that includes the DREAMS, that program you just
    mentioned, but also very importantly continue to expand and
    scale up a PrEP, which is a pre-exposure prophylaxis.
        We believe that these interventions as a basket or a
    collective of odd interventions is what is required in this age
    group.
        The Chairman. Given the youth bulge in Africa and the
    decline in new infections, what might PEPFAR need to do
    differently, if anything, to ensure that we meet the 2030
    targets?
        Dr. Nkengasong. I believe, Mr. Chairman, that we have to,
    as we at PEPFAR are promoting, to really scale-up awareness
    campaigns in the youth population. If you recall, as we have
    all said in this session that 20 years ago the young people
    that we are seeing now did not see the ugly face of HIV/AIDS.
        Across the board, regardless of whether males or females,
    now we see that young age are sexually active and we need to
    create a movement initiative that will create awareness and
    make sure that this young age understands that HIV/AIDS is not
    over.
        The fact that they are not seeing it every day, they do not
    see people lying in hospital beds means that it is over. It is
    far from over.
        The Chairman. Finally, at the International AIDS Conference
    in 2022 participants launched a new global alliance to end AIDS
    in children by 2030.
        Twelve African countries committed to integrate pediatric
    treatment into their national HIV/AIDS plans in the wake of the
    conference, a laudable goal, given that 52 percent of HIV
    positive children worldwide aged zero to 14 years were on
    treatment compared to 76 percent of HIV positive adults.
    Children account for 15 percent of all AIDS-related deaths,
    despite making up 4 percent of total HIV positive cases.
        What are the obstacles to reaching children with treatment
    and how do you plan to address them, and how are you as the
    Global AIDS Coordinator working with African leaders to support
    them in honoring their commitments, including ending AIDS in
    children by 2030?
        Dr. Nkengasong. Thank you, Mr. Chairman.
        The issue of HIV infections in children is critical. If
    you--as I stated in my statement, it is the top priority, one
    of the three key areas that--or priority populations that we
    are engaging, which is the children, adolescent girls, and
    young women and key populations.
        PEPFAR is completely committed and aligned with UNAIDS and
    Global Fund in the lands you just mentioned. After the AIDS
    conference in Montreal, an initiative was launched in Tanzania
    just recently in February where we are all committed to
    ending--to fighting HIV/AIDS in children.
        There are several obstacles that age group--that particular
    population segment faces: ability to access diagnostics, point-
    of-care diagnostics, finding those children in communities, and
    issues of stigmatization.
        We would have to work collectively with partner countries,
    with our Global Fund colleagues and UNAIDS, of course, with WHO
    to continue to advance our basic critical priority, an area of
    inequity that a new strategy highlights clearly.
        As to what we are doing with engagement with the partner
    countries, as I just indicated in my statement, that is a top
    priority for me personally.
        I was on the continent of Africa in February and actually
    for the first time address territory head of states and asked
    for their commitment to the Abuja Declaration as well as to
    recommitting their political will and domestic resources to
    financing HIV/AIDS.
        A special summit is planned for October this year and we
    are working with UNAIDS and, of course, the African Union to
    host that summit, which will focus uniquely on a roadmap to
    getting to 2030, what political commitment, domestic financing,
    and programming are required to partner with us to get us
    there.
        The Chairman. We look forward to that conference.
        Senator Risch.
        Senator Risch. Thank you, Mr. Chairman.
        Ambassador, we have before us a reauthorization, which is
    not uncommon in these legislative halls, and what we are
    talking about here, hopefully, is we use the word ``clean''--a
    ``clean'' reauthorization. It is a legislative term of art.
    ``Clean'' is in air quotes, I guess.
        What is your position on that? The reason I raise this is
    frequently when we do reauthorizations, people strive to make
    something better, but sometimes cause a lot more grief as they
    try to make it better.
        Are you satisfied with what would be a clean
    reauthorization here and that is reauthorizing what we have in
    front of us. Are you satisfied with that?
        Dr. Nkengasong. Senator, I am very satisfied with that.
        As I indicated earlier, I have the authorities in the
    current format to continue to advance our programming. It is
    what has brought us this far to saving 25 million lives,
    preventing 5.5 million children born free of HIV/AIDS, and
    strengthening our health systems that are being used--currently
    used in sustaining the gains in HIV/AIDS, but also positioning
    it to fight other infectious diseases such as Ebola and COVID,
    as we saw.
        I am very convinced that I do have the authority that is
    necessary in the current format of PEPFAR law.
        Senator Risch. I share that view and I hope others do so
    that we can move it rapidly through and not get hung up. We get
    high-centered once in a while when we try to reinvent the
    wheel.
        I do not want to get too far in the weeds here, but we are
    told the Administration has decided to give you some additional
    responsibilities for global health security, but placed the
    additional resources for global health security at USAID.
        Can you speak to this issue at all?
        Dr. Nkengasong. Thank you, Senator.
        As you know, in December of last year Secretary Blinken
    announced the establishment of a new bureau, the Bureau of
    Global Health, Security, and Diplomacy within the State
    Department, which will be headed by myself, and I believe it is
    a very exciting moment because it offers a unique opportunity
    for us to coordinate global health security efforts, to
    leverage assets across USG, and continue to lead with diplomacy
    across the board and those are elements that I believe are so
    critical for protecting ourselves and protecting the world as
    we see and will continue to fight emerging infectious diseases,
    including the current pandemic.
        In doing so, the goal is to consolidate PEPFAR and, of
    course, health security into one bureau that I believe will
    create more efficiencies underneath one roof and under my
    leadership. I am looking forward to when the bureau will be
    fully launched.
        Senator Risch. You are satisfied that you can overcome any
    of the challenges about this dichotomy with responsibility for
    execution versus responsibilities?
        Dr. Nkengasong. Senator, I think we will continue to work
    across the agencies. I think the only way to make the bureau as
    successful as it is intended is to work in unison across the
    Department and across the agencies.
        I think that is the whole intent to increase efficiencies
    and coordination within the global health security space.
        Senator Risch. Thank you. Thank you, Mr. Chairman.
        The Chairman. Thank you.
        Senator Kaine.
        Senator Kaine. Thank you, Mr. Chair, and Dr. Nkengasong,
    thank you for your long, passionate service in this area.
        I want to ask some questions about Latin America, where
    trends are not going in a positive direction. Between 2010 and
    2021, the number of new infections in Latin America increased
    by about 5 percent. That was at the same time as global
    infections were dropping by 32 percent, and even in the
    Caribbean nearby, infections were dropping 28 percent.
        In May, about a year ago during a visit to Panama, the
    First Lady announced some significant additional funding from
    PEPFAR to Latin America, including direct funding to Panama.
        I wanted to ask you, just, how can PEPFAR prioritize its
    engagement in Latin American countries to try to deal with this
    trend that is going in the wrong direction?
        Dr. Nkengasong. Thank you, Senator.
        Any trends in HIV new infections that are headed in the
    new--in a different direction is really concerning because it
    will not--it will continue to be a challenge for us to get to
    our 2030 goals, which we see differences in countries that have
    prioritized HIV response and where resources, especially PEPFAR
    resources and assets, have been applied to. Those tendencies
    are in the right direction and at times are really speeding
    towards the 2030 goals.
        We currently are investing $80 million per year in
    supporting regional programs in the Western Hemisphere. That is
    excluding Haiti, which has a budget envelope of about $100
    million a year.
        We just had a regional meeting in that region just a few
    weeks ago where we brought our countries together to
    strategically develop plans to continue to fight HIV/AIDS in
    the region.
        I think we also want to be sure that it continues to be at
    the fore of the political agenda in the region. I really hope
    that in the coming months I should be able to go to the region
    and continue to maintain that political momentum, which I
    believe is so critical in elevating the issue, because as I
    said earlier, Senator, the HIV/AIDS phase--ugly phase has
    disappeared thanks to our efforts.
        I call that being vulnerable to our own success and we have
    to continuously elevate that issue to the political leadership
    so that it remains visible.
        We will continue to work with the 11 countries in the
    region as equally as we are working in other regions of the
    world.
        Senator Kaine. Excellent. I would encourage you in that,
    and I think one of the challenges in Latin America has been
    political instability, COVID, economic challenges that push
    migrating populations so folks who are disproportionately
    likely to have HIV/AIDS are also pushed, because of factors, to
    move country to country.
        It is a little bit harder sometimes to deal with migrating
    populations, but I would encourage you in that way.
        The second thing I want to ask, really my last question, is
    just for folks following this from the 20th anniversary, we
    think of PEPFAR as a very successful strategy to deal with HIV/
    AIDS.
        It also involved the dramatic investments and improvements
    in the public health infrastructure in many of these countries
    that have benefits far beyond just in the HIV/AIDS space. When
    you build up a public health infrastructure, you are better
    able to deal with COVID, you are better able to deal with other
    conditions.
        Talk a little bit about how PEPFAR's investment in public
    health infrastructure has had benefits even beyond HIV/AIDS.
        Dr. Nkengasong. Thank you, Senator, for that question.
        I usually refer to--when I look back at PEPFAR 20 years ago
    the biblical Lazarus effect reminds me and that is true for
    lives saved, but it is also true for health systems that have
    been improved in countries that we have worked in and
    supported.
        We currently have supported over 3,000 laboratories across
    PEPFAR partner countries, supported over 340,000 healthcare
    workers, invested in over 70,000 health facilities, which are
    really--and several networks and supply chain systems, which
    are currently being used in advancing our goal to ending HIV/
    AIDS by the year 2030, but, in addition, to enabling us to
    fight other emerging infectious diseases, which are occurring
    unfortunately very frequently--the Ebola outbreak in DRC in my
    previous life at the African Union--Africa Centers for Disease
    Control as the director.
        I went to DRC almost twice a year and it is fair to say
    that a lot of infrastructure that we put in place has been very
    handy there. Massive cholera outbreaks, Ebola outbreak recently
    in Uganda benefited a lot from the infrastructure that we have
    put in place, and COVID.
        The PEPFAR infrastructure was very critical early on in
    advancing testing for COVID in Africa, expanding vaccination--
    COVID vaccinations--and infection control prevention measures.
        That effect is there, which has completely transformed
    public health systems in several countries.
        Senator Kaine. I appreciate you describing that clearly.
    The reauthorization is very, very important to get to the
    global goal about eradication of HIV/AIDS by 2030 as a public
    health crisis.
        The additional benefits that we gained by investing in this
    public health infrastructure are virtually incalculable and I
    think that this is why this program has been so successful and
    so supported in a bipartisan way.
        I yield back, Mr. Chair.
        The Chairman. Thank you.
        Senator Booker.
        Senator Booker. Thank you very much, Chairman, and I want
    to thank our witness for his extraordinary leadership for many,
    many years.
        I want to just start by--I think it is really something
    that is good. I strongly support this idea that the established
    PEPFAR infrastructure was so critical during the COVID pandemic
    in helping to meet a lot of the challenges.
        There have been concerns, though, expressed about the
    potential that this approach has to the integrity of the HIV
    and AIDS efforts.
        From where you sit, what have been the benefits of using
    PEPFAR infrastructure for strengthening overall health
    infrastructure and has it negatively impacted the mission
    around HIV and AIDS care and related services?
        I say that understanding that more and more we are seeing
    co-morbidities associated with the deaths, but I am curious,
    from your perspective, what are you seeing?
        Dr. Nkengasong. Thank you, Senator, for that question.
        The way I would describe it is that we need to continually
    support health systems, which is really the workforce,
    laboratory systems, supply chain management, that are required
    primarily in supporting the goal of ending HIV/AIDS as a
    threat--a public health threat by the year 2030.
        Again, just repeating some numbers, we still have a big
    HIV/AIDS pandemic issue with 1.5 million new infections
    occurring every year and 650,000 deaths a year. Of that number,
    about 425,000 deaths occurred in Africa so the pandemic is not
    over.
        By continuously investing in those health systems to
    advance a goal to get to 2030, we very directly or indirectly
    provide a platform for responding to other emerging infections
    without deviating from our core mission, which is to fight HIV/
    AIDS.
        Senator Booker. There is a disconnect right now. Children
    make up 4 percent, roughly, of the global AIDS cases. They make
    about 15 percent of the people that are dying globally from
    HIV/AIDS, and I am wondering where you think--and I know the
    mission, by 2030, there has been a lot of resources focusing on
    this disproportionate levels of death.
        I am wondering what do you see right now as the gaps to
    addressing issues with children, to addressing issues with
    mother-child transmission and more?
        Dr. Nkengasong. Thank you, Senator.
        As I stated earlier, this is a top priority the next 5-year
    strategic plan, which we released on December 1. Children,
    adolescent girls, and young women and the five key populations
    are a top priority.
        We were very intentional in elevating attention to children
    because of the gaps you just outlined. The mantra is knowing
    our gaps and addressing our gaps using science. There are a
    couple of things that we have done in the past.
        As I indicated, 5.5 million children have been born free of
    HIV/AIDS, so we have made progress. In 15 countries we have
    seen remarkable reduction in pediatric HIV/AIDS, including
    Botswana, where, if you recall, Botswana had one of the largest
    burden of HIV in terms of the prevalence of the disease, about
    80 percent of the population. Botswana is very close to
    eliminating pediatric HIV/AIDS.
        There is a lot of work that needs to be done. As you
    already said, there are a lot of inequities in terms of
    bringing in those children--identifying the children, bringing
    them to treatment, and making sure that their viral load is
    suppressed.
        There are a couple of things that we believe we must do:
    increase the testing, develop new tests, especially the point
    of care test that will identify the children early and then
    link them up to treatment.
        Issues of stigmatization--make sure that we have very
    aggressive campaigns that continue to make sure that we
    identify these women in the community and, of course, community
    mobilization because the children are in the communities. If we
    are not finding them; they are in the community.
        That is why we are very proud to be part of the alliance
    that was launched in Montreal at the AIDS conference and also
    recently in Tanzania by--through a combination of UNAIDS,
    Global Fund, WHO, and, of course, member states in Africa. That
    is an alliance that we are committed to because of the unique
    nature of HIV/AIDS in children.
        Senator Booker. My time is running out. I want to point out
    two issues and then maybe hope you can follow up with them.
        One is the significant connection between violence and
    sexual violence against women, child marriages, and the spread
    of HIV/AIDS to women has me deeply concerned, and then the
    other--and the chairman mentioned this, but I want to just
    rehighlight it.
        The Ugandan Government's passage of legislation that
    criminalizes the LGBTQ community is really, really concerning.
        If this bill is signed, there are implications on PEPFAR
    funding and programs in Uganda, given the bill's broad
    criminalization of activities that encourage or observe, ``the
    normalization of LGBTQ issues.'' This bill can actually affect
    our operations and the distribution--and then the work that we
    do, given that criminalization.
        I would love to follow-up with you about the strategies--
    both on what we are seeing in some places, and the high levels
    of violence against women, and I would love to hear your
    thoughts.
        I am the subcommittee chair of the Africa and Global Health
    Subcommittee and really want to find ways that this committee
    could, perhaps, address a lot of these other issues that are
    underlying the spread of HIV and AIDS. The great thing about
    this--and I just want to say that this has been a bipartisan
    issue in my conversations with colleagues on both sides of the
    aisle on this committee. There is a lot of hope for more that
    we could be doing besides just the funding.
        I do want to agree with both the chairman and the ranking
    member. Getting a clean reauthorization is really, I think,
    something that is urgent, given the light of the progress we
    have made and the challenges that we still have.
        Mr. Chairman, thank you.
        The Chairman. Ambassador, just one final--since we have you
    here and I hope to have only just this hearing--I hear the
    chorus on a clean reauthorization. I get it. I have been around
    here long enough to know that we do not need to complicate our
    lives, but it would be a crime that if we know that there is
    something that we can do today that we did not when we
    envisioned this program originally or through its
    reauthorizations, that we did not do it in the search for a
    clean reauthorization.
        Can you tell me--for example, I am thinking about PrEP--can
    you tell me that you have the authority to be able to adjust to
    whatever is discovered and/or whether it be in terms of a
    medicine, a vaccination, a cure, a procedure, that you have the
    wherewithal to be able to adjust so that we can take advantage
    of that?
        Dr. Nkengasong. Let me state, Senator, very clearly that I
    am certain definitely that we have the authorities to do that.
        We currently, as PEPFAR, we have supported over 1.4 million
    PrEP and we hope to continue to use the current authority in
    advancing that especially in the light of new molecules or new
    interventions like the long-acting PrEP that you and I
    discussed when we were in South Africa, the CODEL visit, that
    we have the right authority to scaling that office exactly
    built on the backbone of what we have been doing already that
    we will be able to expand such interventions.
        The Chairman. Okay. Then two last questions.
        In response to a request that I made, the Government
    Accountability Office issued a report entitled, ``The
    President's Emergency Plan for AIDS Relief.'' State has taken
    actions to address coordination challenges, but staffing
    challenges persist.
        The report indicated that PEPFAR has neither identified nor
    addressed underlying causes of persistent workload and
    retention issues at the Department of State, specifically noted
    that 70 percent of the positions at the Office of Global
    Health, the global AIDS coordination headquarters, were vacant.
    Eighty-nine percent of major positions overseas were filled on
    an acting basis.
        I understand that you are working on filling those
    positions and I appreciate your efforts to do so, but what
    impact, if any, has staffing vacancies had on program
    implementation and what are we doing to mitigate those
    challenges?
        Dr. Nkengasong. Thank you, Senator.
        When I came in about 9 months ago, that issue--I read your
    report and we have been working very actively and aggressively
    in that. Out of the 90 vacancies that I met, we have filled in
    34 of them in 9 months, which I believe is remarkable--good
    progress.
        I hope that we will continue to work aggressively to fill
    in those positions because they have very direct consequences
    on morale, burn-out, and the ability to have work-life balance,
    which is so critical in our ability to continue to supporting
    countries, the 55 partner countries that we have.
        The same issues we see in the field and that is a major
    focus of us to continue to work with the partner country--our
    programming in the countries to make sure that the vacancies
    are actually filled in a timely fashion.
        My priority, again, was to fill in those headquarters
    positions aggressively as much as possible and I think I am
    very encouraged with the progress we have made so far.
        The Chairman. Okay.
        Then, finally, in the course of briefings on the FY24
    budget requests, it has been mentioned of an Ambassadors Fund.
    Can you tell me exactly what is the purpose of that? Are you
    familiar with it?
        Dr. Nkengasong. Senator, I will need to check on that. Then
    we will get back to you.
        The Chairman. Okay. If you could inform the committee of
    what is the purpose of the Ambassadors Fund, how much money is
    currently in it, how have funds been used in past years, and
    how do you plan to use them for your priorities over the next 5
    years, it would be helpful as we deal with the budget process.
        Dr. Nkengasong. I will definitely get back to you.

    [Editor's note.--The requested information referred to above
    follows:]

        While we do not have a formal fund called the Ambassador's Fund. It
    is possible this question refers to funding that S/GAC has in reserve,
    which some may have referred to as an ``Ambassador's Fund.'' The
    primary purpose of the reserve is to ensure sufficient funding is
    available for responsible programming as we take into account all
    available funding and needs and to address two primary risks: 1)
    unforeseen circumstances; and 2) the risk of further decreases in
    available pipeline funding that PEPFAR relies on to continue
    operations.
        S/GAC has a robust pipeline management process where unused funds
    from prior years are explicitly brought forward into the next Country
    Operational Plan (COP) cycle as applied pipeline, thereby ensuring that
    resources are spent on the most current needs based on the most up-to-
    date data, and also preventing the buildup of pipeline that cannot be
    effectively utilized during a COP cycle.
        In the COP22 process we are relying on a total of $336 million in
    applied pipeline, which enables us to run a program that is larger than
    we would be able to if we were to rely on newly appropriated funds
    alone. However, that means that if applied pipeline declines in the
    future, we would have to reduce programming under a flat appropriation,
    unless we have reserve funding available. Applied pipeline has come
    down from $813 million in COP19 to about $251 million in COP23 as
    agencies have effectively programmed and spent the full amount budgeted
    in each COP year.
        In addition to the two primary purposes noted above, some funds in
    reserve at the beginning of the current Administration were there to
    ensure that Ambassador Nkengasong would have flexibility for new
    programming to address high priority needs related to reaching and
    sustaining the 95-95-95 goals.
        At the start of the COP23 planning process, the reserve totaled
    approximately $400 million. While COP and Headquarters Operational Plan
    (HOP) 23 planning is still underway, we expect that at the conclusion
    of COP/HOP23 planning and subsequent Congressional Notification, the
    reserve would be approximately $170 million. With the reserve, we were
    able to: 1) plan for a total of $42 million in increased funding to
    several counties due to contingencies or changing circumstances
    (Angola, Ethiopia, Haiti, Mozambique, and Ukraine), 2) prioritize $40
    million for high priority health equity initiatives across more than 30
    countries in the COP, and 3) plan for approximately $71 million for
    critical surveys that will enable us to understand the needs of our
    populations as we aim to reach 95-95-95 and beyond. Additionally, we
    planning to fund $95 million in critical priority initiatives related
    to youth, national public health institute strengthening, injectable
    prep, nursing and community health worker leadership, people-centered
    care and advancing the enabling environment for regional manufacturing.
        At $170 million, the reserve is approximately 3 percent of the
    total $5.1 billion that we plan and spend annually in the COP and HOP.
    If applied pipeline drops further in the future, the reserve would be
    used in future cycles to help slow the pace at which decreases would
    need to be made to programs. If applied pipeline approached zero, the
    need for the reserve would be greatly reduced with the need for only a
    limited amount for unforeseen contingencies.

        The Chairman. Senator Cardin has gotten here in the nick of
    time.
        Senator Cardin. Thank you.
        First, thank you very much for your service. We appreciate
    it very much. I want to follow up on Senator Booker's point in
    regards to the benefits of PEPFAR being far beyond just dealing
    with HIV/AIDS.
        It builds up capacity, healthcare, infrastructure to deal
    with the challenges in the countries in which we are operating,
    and it has been transformational and it has been extremely
    successful. We are very proud of that part of it.
        We know that the PEPFAR strategy notes that there is a goal
    of 70 percent of the resources going for localization. Senator
    Hagerty and I held a subcommittee hearing dealing with USAID
    and localization, building up local capacity, but we also
    understand there is challenges in meeting that particular
    commitment.
        Can you just share with us your commitment to make sure
    that we have tried--that we reach that goal, that we do make a
    significant commitment to making sure the resources are going
    locally so that it not only deals with the direct challenges of
    PEPFAR, but it provides the type of infrastructure in the
    country to deal with the healthcare challenges?
        Dr. Nkengasong. Thank you, Senator.
        I think when I came on board about 9 months ago that was
    one of my top priorities, the priority of sustainability, and I
    see that in the lens--the light of programmatic sustainability,
    that we will be able to sustain these programs if we have many
    more local partners that are capable.
        I have taken a very hard look at that and what I am
    currently doing now is to make sure that we do not really get
    to 70 percent, but we get to 70 percent with strong local
    partners that have good fiscal systems, procurement systems,
    governance as a whole.
        I am currently developing tools that will be used in
    assessing all our local partners, identifying gaps that we need
    to apply ourselves to and support them, and not punish them,
    but support them so that they can build that capacity in a
    sustained manner, which is a top priority for me in doing that,
    at the same time recognizing that we need to continue to have a
    mixture of those local partners and international partners to
    get us to 2030 because that is the ultimate goal that we have
    set for ourselves.
        Senator Cardin. I totally agree that there has to be
    capacity locally. We want to make sure our resources are
    appropriately used. Completely agree with you on that, but many
    times it is used as an excuse because of the existing partners
    that we have trying to preserve their share of our foreign
    assistance and, therefore, we do not really build the type of
    local capacity because of the existing contracts that we have
    in country.
        How do you guard against that type of natural bias against
    bringing in new partners that are sharing the resources?
        Dr. Nkengasong. Thank you, Senator.
        That is exactly why I have decided to develop a tool that
    will truly tell us where--using evidence and data that where we
    are with this partner.
        Say, for example, if we have 400 partners where are they--
    where is the capacity so that the discussion about the capacity
    does not exist or exists should be off the table.
        It is only through an evidence-based, systematic, and
    standardized process that we can be able to answer that
    question and provide you with the right answer there.
        I am committed to that process.
        Senator Cardin. Will you provide this committee with where
    you are on reaching that 70 percent goal and the challenges
    that you are having per country as far as capacity building so
    that we understand the challenges you are confronting and,
    perhaps, can be your partner to expedite local capacity?
        Dr. Nkengasong. Absolutely, Senator. I will do that.
        Senator Cardin. Thank you.

    [Editor's note.--The requested information referred to above
    follows:]

        Regarding the goal of 70 percent of PEPFAR funding going towards
    local partners, the PEPFAR program is currently estimated at 59 percent
    based on the COP22 budget (see chart below). We expect further progress
    towards the 70 percent target be made over the next 2 years as part of
    the COP23 implementation.
        In the PEPFAR 5-year strategy released in December, we highlighted
    the importance of national capacity building to enable the long-term
    sustainability of the HIV response. We believe that the key to
    operationalizing this component of the strategy will be to accurately
    assess the current capabilities of our local implementing partners in a
    standardized manner across the program--especially on operational
    dimensions like financial management and governance. Post this, the
    PEPFAR program will provide targeted capability building support to
    critical local partners in order to measurably advance their
    capabilities. This will ultimately enable those partners to take on a
    greater responsibility for the future service delivery needs of the
    program.
        We have set up an interagency national capacity building taskforce
    within PEPFAR who is responsible for advancing this work. We have and
    will also continue to invest meaningful time and effort to increase the
    depth and breadth of the financial and operational data we collect on
    all our partners (including local partners) to improve our oversight
    and prevent any fraud, waste and abuse.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The Chairman. Thank you, Senator Cardin.
        Thank you, Dr. Nkengasong, for your service, for your
    testimony here today. We may still call upon you as we get to
    the final reauthorization. There are a couple of pending
    questions you are going to get back to us on, and with the
    thanks of the committee you are excused at this point.
        Dr. Nkengasong. Thank you, Senator.
        The Chairman. As Dr. Nkengasong leaves the dais, let me
    begin to introduce our two next witnesses.
        Joining us virtually today from London is Sir Elton John, a
    world-renowned singer, songwriter, philanthropist. In 1992, Sir
    Elton established the Elton John AIDS Foundation, which today
    is the sixth largest AIDS funder globally.
        Through more than 3,000 projects in 90 countries, the
    foundation has helped save the lives of over 5 million people
    and raise awareness of HIV. Sir Elton has traveled extensively
    in Africa, where I was privileged to join him in February,
    Eastern Europe, and across the United States.
        He has spoken several times at the United Nations here in
    the Senate using his platform to advocate for people living
    with or at risk of HIV.
        In 2022, Sir Elton was awarded the Humanitarian Medal by
    President Biden at the White House. In 1998, he was knighted by
    Queen Elizabeth II for his charitable achievements. We welcome
    him.
        Joining him on the panel here in Washington is Dr. Mark
    Dybul, a professor at Georgetown University Medical Center,
    where he serves as chief strategy officer at the Center for
    Global Health Practice and Impact, executive chair of Platform
    Life Sciences, and CEO of Enochian Biosciences.
        Dr. Dybul has worked on HIV and public health for more than
    25 years as a clinician, scientist, teacher, and administrator.
        Dr. Dybul was appointed by President Bush as the second
    U.S. Global AIDS Coordinator in 2006, served in that capacity
    until 2009, has served as executive director of the Global Fund
    to Fight AIDS, Tuberculosis, and Malaria from 2013 to 2017.
        Welcome to both of our witnesses and I would ask Sir Elton
    to please proceed with your testimony.

         STATEMENT OF SIR ELTON JOHN, FOUNDER, ELTON JOHN AIDS
                   FOUNDATION, LONDON, UNITED KINGDOM

        Sir Elton. Good morning, Chairman Menendez, Ranking Member
    Risch, and distinguished members of the committee. I am
    delighted to join you today to wholeheartedly support your
    commitment to extending the lifesaving work of the landmark
    PEPFAR program.
        I was humbled to have been part of your recent bipartisan
    fact-finding mission to South Africa to experience the awe-
    inspiring impact this program is having on the ground. It was
    an inspirational visit that shows the immense gratitude of the
    African people.
        I want to begin by thanking you for your continued focus on
    the global fight against AIDS. We are living in deeply troubled
    times with countless global challenges, all of which I know
    beckon your time and attention.
        Beyond that, I am boundlessly grateful for the bipartisan
    cooperation that has been the hallmark of PEPFAR for two
    decades now. While this effort was initially conceived by
    President Bush, it has been enthusiastically supported by four
    presidents and 10 Congresses and consistently championed by the
    generosity of the American people.
        As I testified to the Senate 21 years ago this week, what
    America does for itself has made it strong, but what America
    does for others has made it great. Bravo, my friends. There is
    no better symbol of American greatness than PEPFAR and you
    should all be very proud of your extraordinary efforts.
        Before PEPFAR, much of Africa was in freefall. Infant child
    mortality was skyrocketing, life expectancy plummeting, and
    decades of development progress being rolled back.
        Families across the continent were walking miles to bring
    their loved ones to hospitals in wheelbarrows where they were
    piled up three to a gurney in hallways because every inch of
    the hospital was already full.
        In some communities, half of the adults were HIV positive.
    In others, 80 percent of pregnant women were. A generation of
    young parents and workers were being wiped out, leaving
    grandparents and older siblings to raise millions of orphans.
        More than 30 million individuals were already HIV-positive,
    but less than 50,000 in poor countries had access to lifesaving
    drugs. GDP was dropping and coffin-making was the booming
    business of the day, including mountains of 24-inch coffins for
    babies. It was beyond bleak and the future projections even
    worse.
        In those dark days there was little my AIDS Foundation
    could do for the millions suffering in secret because of the
    stigma of AIDS. In South Africa, where more than a quarter
    million people were dying of AIDS each year, we provided basic
    care to nearly a million people in hopes that they could at
    least die with dignity.
        We gave them food, clean water, bedding, blankets,
    aspirins, ointments, a hand, a prayer, and a plan for their
    children once they were gone, but those were the only tools we
    had at our disposal at the time.
        I looked into the eyes of way too many dying people begging
    for help and hope that was just not possible and available. For
    them, AIDS was a death sentence every time.
        Then came you, compassionate American leaders who decided
    that it was better to light a candle than to curse the
    darkness, who decided that whether a mother or child lived or
    died should not be left to a lottery or geography, and who
    decided that American generosity and genius could literally
    change not just the course of the pandemic, but the course of
    history, and it has.
        Thanks to PEPFAR, horror finally gave way to hope. ARV
    treatment became available and people all of a sudden living
    with HIV literally rose out of their hospital beds and went
    home to resume their lives and livelihoods.
        In the 20 years since, PEPFAR has saved 25 million lives,
    more than twice the number of people living in New Jersey and
    Idaho. That is a lot of lives, and AIDS deaths have been cut by
    60 percent and new HIV infections by more than half.
        Hundreds of thousands of doctors, nurses, and community
    health workers have been trained, lab and surveillance systems
    have been established, and community-based organizations or
    mobile clinics have been created to bring essential prevention
    treatment and support services closer to the people in need.
        Part of PEPFAR's power was demonstrating the art of the
    possible. Nelson Mandela often said, they all say it is
    impossible until it is done, and that is true for PEPFAR. Many
    said we could never provide lifesaving treatment in Africa. It
    was too complicated and too expensive, but PEPFAR proved that
    was nonsense and now millions of people--20 million people in
    Africa are being supported on treatment and 6 million people in
    South Africa alone, and mostly paid for by their own
    government.
        As a result, life expectancy is up by 12 years in South
    Africa, 20 years in Zambia, and the PEPFAR platform has not
    only transformed HIV into a chronic disease for tens of
    millions, it has been leveraged to fight COVID and made
    countries far better prepared for whatever viral nightmare
    comes next.
        This is great news and a tribute to American leadership,
    persistence, and strategic investment. We are not done yet.
    According to UNAIDS, our progress is faltering as one person
    with AIDS dies and three new people become infected with HIV
    every minute.
        While AIDS deaths and new infections are falling for most
    age groups, they remain on the rise for young people between
    the ages of 15-24, particularly young women and girls, and this
    is especially concerning in Africa where the average age is 18
    and where AIDS remains the leading cause of death among teens.
        For young people who are not yet born during the horrors of
    AIDS, they need a wakeup call, accurate information, and the
    power to use it. In South Africa my AIDS Foundations have
    partnered with digital platforms to reach young people where
    they are, on their smart phones, with relatable information and
    services that resonate with them.
        Twenty thousand have joined the platform in the first month
    and they expect 100,000 in 3 months, just in South Africa. In
    Kenya, we are working with the first drone delivery company
    that enables young people with cell phones to order affordable
    medicine and supplies and receive them within 1 hour. These
    innovations not only engage and empower young people, they save
    both money and lives.
        In conclusion, you should be rightfully proud of what you
    have created and the impact that this had and is still having.
    We have the tools and we need to turn the tide and,
    increasingly, national leadership, capacity, and ingenuity are
    taking what is good and making better and more sustainable.
        We need to keep our foot on the accelerator. We have come
    so far in such a short time relatively. By extending PEPFAR for
    another 5 years and fully funding it, together we can continue
    the march towards ending AIDS for everyone everywhere and leave
    no one behind.
        Thank you so much for all you do. I give you so much love
    from United Kingdom. Thank you.
        [The prepared statement of Sir Elton follows:]

                      Prepared Statement of Sir Elton John

        Good morning, Chairman Menendez, Ranking Member Risch and
    Distinguished Members of the Committee. I am delighted to join with you
    today to wholeheartedly support your commitment to extending the
    lifesaving work of the landmark PEPFAR program.
        I was humbled to have been a part of your recent bipartisan fact-
    finding mission to South Africa to experience the awe-inspiring impact
    this program is having on the ground.
        I want to begin by thanking you for your continued focus on the
    global fight against AIDS. We are living in deeply troubled times with
    countless global challenges--all of which I know beckon your time and
    attention. Given that, I am boundlessly grateful for the bipartisan
    cooperation that has been the hallmark of PEPFAR for 2 decades now.
        While this effort was initially conceived of by President Bush--it
    has been enthusiastically supported by 4 Presidents and 10 Congresses
    and consistently championed by the generosity of the American people.
    As I testified to this Senate 21 years ago this week--``what America
    does for itself has made it strong--but what America does for others
    has made it great.'' Bravo my friends--there is no better symbol of
    American greatness than PEPFAR--and you should all be very proud of
    your extraordinary efforts.
        Before PEPFAR--much of Africa was in free fall. Infant/child
    mortality was skyrocketing, life expectancy plummeting, and decades of
    development progress being rolled back. Families across the continent
    were walking miles to bring their loved ones to hospitals in
    wheelbarrows where they were piled up three to a gurney in hallways . .
    . because every inch of the hospital was already full. In some
    communities, half of the adults were HIV positive. In others, 80
    percent of pregnant women were. A generation of young parents and
    workers were being wiped out, leaving grandparents and older siblings
    to raise millions of orphans. More than 30 million individuals were
    already HIV positive but less than 50,000 in poor countries had access
    to lifesaving drugs. GDP was dropping and coffin making was the booming
    business of the day--including mountains of 24-inch coffins for babies.
    It was beyond bleak and the future projections even worse.
        In those dark days, there was little my AIDS Foundation could do
    for the millions suffering in secret because of the stigma of AIDS. In
    South Africa, where more than a quarter of a million people were dying
    of AIDS each year, we provided basic care to nearly a million people in
    hopes that they could at least die with dignity. We gave them food,
    clean water, bedding, blankets, aspirin, ointments, a hand, a prayer,
    and a plan for their children once they were gone--but those were the
    only tools we had at our disposal at the time. I looked into the eyes
    of way too many dying people begging for help and hope that was just
    not available. For them--AIDS was a death sentence, every time.
        And then came you--compassionate American leaders who decided that
    it was better to light a candle than to curse the darkness. Who decided
    that whether a mother or child lived or died should not be left to a
    lottery of geography. And who decided that American generosity and
    genius could literally change, not just the course of the pandemic, but
    the course of history. And it has.
        Thanks to PEPFAR, horror finally gave way to hope. ARV treatment
    became available and people--suddenly ``living'' with HIV--literally
    rose out of their hospital beds and went home to resume their lives and
    livelihoods.
        In the 20 years since, PEPFAR has saved 25 million lives--more than
    twice the number of people living in both New Jersey and Idaho. That's
    a lot of lives. AIDS deaths have been cut by 60 percent and new HIV
    infections by more than half. Hundreds of thousands of doctors, nurses
    and community health workers have been trained. Lab and surveillance
    systems have been established, and community-based organizations and
    mobile clinics have been created to bring essential prevention,
    treatment, and support services closer to the people in need.
        Part of PEPFAR's power was demonstrating the art of the possible.
    As Nelson Mandela often said: ``They always say it's impossible until
    it's done.'' And that's true for PEPFAR. Many said we could never
    provide lifesaving treatment in Africa--it was too complicated and too
    expensive. But PEPFAR proved that was nonsense and now millions of
    people 20 million people in Africa, are being supported on treatment, 6
    million in South Africa alone, and mostly paid for by their own
    government. As a result, life expectancy is up by 12 years in South
    Africa . . . 20 years in Zambia. And the PEPFAR platform has not only
    transformed HIV into a chronic disease for tens of millions--it has
    been leveraged to fight COVID and made countries far better prepared
    for whatever viral nightmare comes next. This is great news and a
    tribute to American leadership, persistence, and strategic investment.
        But we are not done yet. According to UNAIDS, our progress is
    faltering as one person with AIDS dies and 3 new people become infected
    with HIV every minute. While AIDS deaths and new infections are falling
    for most age groups--they remain on the rise for young people ages 15-
    24, particularly young women and girls. And this is especially
    concerning in Africa where the average age is 18 and where AIDS remains
    the leading cause of death among teens. For young people who were not
    yet born during the horrors of AIDS--they need a wake-up call, accurate
    information, and the power to use it.
        In South Africa, my AIDS Foundation has partnered with digital
    platforms to reach young people where they are--on their smartphones--
    with relatable information and services that resonate with them. Twenty
    thousand have joined the platform in its first month and they expect
    100,000 in 3 months, just in South Africa. In Kenya, we are working
    with the first drone delivery company that enables young people with
    cell phones to order affordable medicine and supplies and receive them
    within an hour. These innovations not only engage and empower young
    people--they save both money and lives.
        In conclusion, you should be rightfully proud of what you have
    created and the impact it has had and is still having. We have the
    tools we need to turn the tide and increasingly national leadership,
    capacity and ingenuity are taking what is good and making it better and
    more sustainable--but we need to keep our foot on the accelerator. By
    extending PEPFAR for another 5 years and fully funding it, together, we
    can continue the march toward ending AIDS for everyone everywhere and
    leave no one behind. Thank you.

        The Chairman. Well, thank you, Sir Elton, and let me return
    the compliment. Thank you for what you have done. Some people
    use their fame in a way that only enriches themselves.
        Others use their fame in a way that saves the lives of
    others, and in your case that has certainly been the case, so
    thank you for what you have done.
        Dr. Dybul.

       STATEMENT OF THE HONORABLE MARK DYBUL, M.D., PROFESSOR OF
      MEDICINE AND CHIEF STRATEGY OFFICER, GEORGETOWN UNIVERSITY
          MEDICAL CENTER FOR GLOBAL HEALTH PRACTICE AND IMPACT

        Dr. Dybul. Chairman Menendez, Ranking Member Risch, and
    distinguished members of the committee, thank you for the
    privilege to be before this body again to discuss the
    reauthorization of PEPFAR, which has been called and I believe,
    in fact, is the most successful global health program in
    history.
        Thank you for the--to the members and staff who have
    provided steadfast support in a bipartisan way for two decades.
        Ambassador Nkengasong and Elton have provided you with the
    breathtaking data on the lifesaving impact of PEPFAR. I would
    like to spend a few moments focusing on other lasting legacies
    including the diplomatic benefit from villages to state houses,
    health system strengthening, and enhanced health security.
        In 2006 when I was the U.S. Global AIDS Coordinator, I was
    fortunate to visit Axum, Ethiopia, which is believed to be the
    birthplace of Christianity in Africa. At dawn, with the mist
    over the town, which blocked the electrical wires, it looked as
    it might have centuries ago.
        Local farmers were winding through the streets with donkey-
    drawn carriages. The spires of the churches peek through the
    haze. Bells rang all to prayers in the market. We were met at
    the local clinic by the director and his team.
        Now, in a town that small the director of the clinic is an
    elder, a very important person in the village. He kept
    referring to PEPFAR. I was a little bit cranky from not
    sleeping for a couple of days and so I asked him what does
    PEPFAR mean.
        His answer knocked me over. He said, PEPFAR means the
    American people care about us. The American people care about
    us. That wonderful phrase captured the sentiments I have heard
    from nearly every corner of Africa, sentiments that have grown
    with every life saved and as individuals, families, communities
    and nations have moved from total despair to the hope for the
    future.
        Now, hope is not just a matter of faith or a good feeling.
    It awakens a lost desire to find a job, go to school, feed your
    family, care for your community. It is, in fact, the basis of
    economic growth and the development of markets for U.S. goods
    and services.
        Indeed, prior to COVID, Africa as a region had the second
    fastest growing economy in the world. Ambassador Nkengasong
    noted the positive impact of PEPFAR on GDP. However, there is
    also a diplomatic benefit.
        Senators Risch and Daschle, who were majority and minority
    leaders when PEPFAR was first authorized, led an assessment of
    the Bipartisan Policy Center on the impact of PEPFAR on the
    perceptions of the United States in sub-Saharan Africa.
        In PEPFAR-supported countries, 68 percent of respondents
    had a positive view of our country compared to only 46 percent
    in non-PEPFAR-supported countries. In fact, many African
    countries have a higher view of the United States than the
    United States.
        Those results could be in part due not only to the direct
    impact of HIV on programs, but also because of the broader
    health system strengthening benefits of PEPFAR. Treatment and
    prevention of HIV is lifelong, requiring well-trained health
    providers including community health workers, pharmacists, and
    pharmacies, lab technicians and laboratories, logistics supply
    chains, communication systems, and much more.
        These systems are public, but also private, including the
    faith community. Now, at the beginning, because of stigma and
    discrimination, many of these services were found in separate
    locations.
        However, over time they have become integrated. They are in
    one place. Doctors, nurses, lab techs, pharmacists, community
    health care workers, and all the support systems are there for
    HIV, but also for non-HIV. For that reason, it is not
    surprising that studies have shown that PEPFAR is associated
    with a significant improvement in six out of seven key
    indicators of maternal and child health, including reducing
    rates of mortality for women and children and childhood
    immunization.
        The power of improved health systems was clearly
    demonstrated during the height of the COVID pandemic as has
    been discussed. PEPFAR systems were used to respond to the
    pandemic and Africa would have had a difficult time without it.
        As a former executive director of the Global Fund to Fight
    AIDS, TB, and Malaria, which as you know is also authorized by
    the legislation, I would like to thank the committee for your
    support for that program as well.
        The 33 percent cap there ensures that the American people
    are not the only taxpayers supporting the response to the
    pandemic. The Global Fund plays a key and complementary role
    and our engagement in it also helps us diplomatically by being
    involved multilaterally.
        It has been an extraordinary 20 years. PEPFAR is often
    compared to the Marshall Plan without exaggeration, given what
    you have heard from Elton and Ambassador Nkengasong about the
    ravages of HIV in Africa.
        As this committee knows, it is now a world--we are now in a
    worldwide struggle to ensure that democracy and the global
    economy thrives. While we must lead we also need allies,
    including an Africa where democracy is threatened and where we
    have lost ground as the number-one trading partner.
        Clearly, PEPFAR is not sufficient, but after nearly a
    quarter century of working with Africans at all levels, the
    wisdom of the words from Axum 15 years ago ring truer than
    ever.
        PEPFAR means the American people care about Africans.
    People know what we stand for when we stand with them. With
    your continued support, untold millions of lives will continue
    to be lifted up and saved, strengthened systems for health will
    occur, and we will be in a better position to respond to future
    pandemics and our values will flourish. That will be another
    remarkable legacy for this committee and the American people.
        Thank you for listening and I look forward to your
    questions.
        [The prepared statement of Dr. Dybul follows:]

                      Prepared Statement of Dr. Mark Dybul

        Good morning Chairman Menendez, Ranking Member Risch and
    distinguished members of the Committee. Thank you for the privilege to
    be before this Body again to discuss the Reauthorization of PEPFAR,
    what has been called--and I believe in fact is--``the most successful
    global health program in history.'' It has been the honor of a lifetime
    to have been one of the architects of the original plan adopted by this
    Committee in 2003, and to have been deeply engaged with the program for
    two-thirds of my professional life. Please accept heartfelt thanks to
    all the Members and Staff who have provided steadfast support in a
    bipartisan way for two decades.
        Ambassador Nkengasong and Elton have provided you with breathtaking
    data on the life-saving impact of PEPFAR. I would like to spend a few
    minutes focusing on other lasting legacies, including the diplomatic
    benefit from villages to State Houses, health systems strengthening and
    enhanced health security.
        With your indulgence, I would like to begin with a story that
    remains vivid in my memory. In 2006, while I was the U.S. Global AIDS
    Coordinator, I was fortunate the visit Axum, Ethiopia, believed to be
    the birthplace of Christianity in Africa. At dawn, with the mist over
    the town blocking the electrical wires, it looked as it might have
    centuries ago. Local farmers winding through the streets with donkey-
    drawn wagons, the spires of the churches peaking through the haze,
    bells ringing to call all to prayers and the market. We were met at the
    local clinic by the director and his team. In a town that small, the
    clinic director was also a town elder and leader in the community. He
    kept referring to PEPFAR. I was cranky from too little sleep so asked
    him what PEPFAR means. His answer knocked me over. He said, ``PEPFAR
    means the American people care about us.''
        That wonderful phrase captured the sentiments I have heard from
    nearly every corner of Africa--one that has grown with every life saved
    and as individuals, families, communities and nations moved from total
    despair to hope for the future. Hope is not just a matter of faith or a
    good feeling. It awakens a lost desire to find a job, go to school,
    feed a family, care for your community. It is, in fact the basis for
    economic growth and the development of markets for U.S. goods and
    services. Indeed, prior to the COVID pandemic, Africa, as region, had
    the second fastest growing economy in the world.
        Ambassador Nkengasong noted the positive impact of PEPFAR on GDP
    growth. However, there is also a diplomatic benefit. Senators Frist and
    Daschle, who were the Senate's Majority and Minority leaders when
    PEPFAR was first authorized, led an assessment by the Bipartisan Policy
    Center of the impact of the program on perceptions of the United States
    in Sub-Saharan Africa. In PEPFAR supported countries, 68 percent of
    respondents had a positive view of our country, compared to only 46
    percent in non-PEPFAR supported countries. In fact, many PEPFAR-
    supported countries have a higher percent positive view of the United
    States than the United States.
        Those results could, in part, be the result not only of the direct
    impact on HIV, but also because of the broader health systems
    strengthening benefits of PEPFAR. Treatment and prevention of HIV is a
    life-long enterprise requiring well trained health care providers
    including community health care workers, pharmacists and pharmacies,
    lab technicians and laboratories, logistics, supply chains and
    communications systems and much more. These systems are public but also
    private, including faith-based organizations that have been estimated
    to provide 30-50 percent of health care in Africa, particularly in the
    poorest communities.
        At the beginning, because of stigma and discrimination, many HIV
    services were provided in separate locations. However, over time, the
    vast majority of HIV-related activities occur in general health care
    settings. So the doctors, nurses, lab techs, pharmacists, community
    health workers--and all the support systems--serve non-HIV roles as
    well. For that reason, it is not surprising that studies have shown
    that PEPFAR is associated with a significant improvement in 6 out of 7
    key indicators of maternal and child health including rates of
    mortality for women and children and childhood immunization.
        The power of those improved health systems was clearly demonstrated
    during the height of the COVID pandemic. PEPFAR-supported viral testing
    was used to detect the virus, clinics, hospitals and community workers,
    and commodities procured were all used to help combat the virus.
    Looking to the future and the threat of another pandemic, the best way
    to ensure early detection and to respond rapidly is to maintain and
    strengthen the capacity to respond to an ongoing pandemics, such as
    HIV, with an intentional design for surge capacity when needed.
        As a former Executive Director of the Global Fund to Fight AIDS,
    Tuberculosis and Malaria, which, as you know, the legislation also
    authorizes, I would like to thank the Committee for its support of that
    important organization. With the 33 percent cap on contributions from
    the United States, it is a potent means to help ensure the American
    taxpayer is not alone in this fight. The Global Fund also plays a key,
    and complementary role in building health systems and pandemic
    preparedness and response. And our engagement in a results-driven
    international organization contributes to our diplomatic efforts.
        It has been an extraordinary 20 years. PEPFAR has recently been
    hailed as the best policy decision of the past 50 years and is often
    compared to the Marshall Plan--without exaggeration given what you have
    heard from Elton and Ambassador Nkengasong about the ravages of HIV in
    Africa.
        As this Committee knows, the United States is now in a global
    struggle to help ensure that democracy and a global economy thrives.
    While we must lead, we must have allies including, and perhaps
    particularly, in Africa where democracy is threatened and where we have
    lost ground as the number one trading partner. Clearly, PEPFAR alone is
    not sufficient. But after nearly a quarter Century of working with and
    supporting Africans at all levels, the wisdom of the words from Axum 15
    years ago rings truer than ever: PEPFAR means the American people care
    about Africans.
        We are fortunate to have Amb. Nkengasong, an African-born American,
    leading the effort. He has been with PEPFAR since day 1, first building
    laboratory capacity in Cote d'Ivoire, and then leading that effort
    globally for the U.S. CDC. He went on to be the founding Director of
    the Africa CDC. In that capacity, he led the most successful regional
    response to COVID in the world. As a result, he is still on speed dial
    with many Heads of State, Ministers and providers. He uniquely knows
    how to build systems to effectively respond to HIV while promoting
    health systems. He will lead a renewed diplomatic effort on the
    Continent and help prepare for the next pandemic. He will be the best
    U.S. Global AIDS Coordinator yet.
        People know what we stand for when we stand with them. With your
    continued support, untold millions of lives will continue to be lifted
    up and saved, strengthened health systems for the ongoing HIV pandemic
    will continue to improve the health of mothers, children, communities
    and nations. Those systems will better prepare us for, and help respond
    to, the next pandemic threat. And our values will flourish. That will
    be another remarkable legacy for this Committee and the American
    people.

        [The testimony of Dr. Eric Goosby and Dr. Richard Marlink
    follows:]

              Testimony of Dr. Eric Goosby and Dr. Richard Marlink

                          Ambassador Eric Goosby, M.D.
                      Distinguished Professor of Medicine
                Director of Global Health Delivery and Diplomacy
                      Institute of Global Health Sciences
                    University of California, San Francisco

                             Richard Marlink, M.D.
              Founding Director of Rutgers Global Health Institute
         Inaugural Henry Rutgers Professor of Global Health at Rutgers
                       The State University of New Jersey

        We are at a remarkable time in history. We are celebrating the 20th
    year of the most ambitious health program ever undertaken with
    phenomenal impact and continuing promise. It is an honor to offer our
    perspectives as the Committee addresses the important task of
    reauthorizing PEPFAR and ensuring this life-saving work continues. It
    is a sign of America at its best.
        When each of us began working on the issue of HIV/AIDS in the early
    1980's, no one knew what this silent killer was or the impact it would
    have on the world. What we were faced with was a mysterious disease
    that was a certain death sentence for those in its path, a time we will
    never forget. With the advances of science, the world was changed with
    the discovery of anti-retroviral therapies (ART), restoring lives and
    giving hope to families and whole communities here in America. Yet, for
    many countries including those across Africa most heavily burdened by
    HIV/AIDS, millions were dying and doctors and caregivers could do
    nothing to save them. The sale of coffins was a booming industry. In
    2003, an estimated 3 million people died from AIDS, a quarter million
    in South Africa alone.
        That all changed with the advent of PEPFAR.
        In 2003, President George W. Bush took the historic step of
    creating the U.S. President's Emergency Response for AIDS Relief,
    declaring that ``seldom has history offered a greater opportunity to do
    so much for so many.'' In the last 20 years PEPFAR has changed the
    course of the HIV/AIDS pandemic and the course of history. You have
    seen the numbers--as of FY 2022, 25 million lives have been saved and
    millions more are HIV-free, more than 20 million people are on ART, and
    64.7 million people have received testing services. And there's more--
    2.9 million adolescent girls and young women reached with comprehensive
    HIV prevention services, 7.7 million orphans, vulnerable children and
    their caregivers provided with critical support, and 30 million
    voluntary medical male circumcisions performed to prevent HIV
    infections in men and boys.
        But the success of PEPFAR goes beyond these statistics. We have
    witnessed the restoration of livelihoods and communities thriving
    where, previously, a generation of young and working parents had been
    lost to AIDS. Economies of countries and local stability have been
    restored as life expectancy has recovered, enabling a better future for
    so many. For this, and for the many benefits investment in the global
    HIV/AIDS fight has afforded, America has earned appreciation and
    respect across Africa due to the generosity of the American people.
        Time is never static. To date, 10 Congresses and four
    Administrations have reauthorized the program, reaffirming the
    important work that PEPFAR carries out. This unwavering support
    continues to demonstrate U.S. leadership in advancing effective
    strategies to end HIV/AIDS as a public health threat by 2030 while also
    strengthening systems of care that advance our global health security.
    Now, under the leadership of U.S. Global AIDS Coordinator Ambassador
    John Nkengasong, the role of PEPFAR as a model for effective
    partnerships continues towards the goal of countries managing and
    sustaining effective responses to epidemics now and into the future.
        We have learned much over time. In the earliest days, PEPFAR
    provided urgent support and technical assistance to bolster health care
    capabilities, including diagnostic capacities and ARVs that began to
    change the wave of AIDS across Africa. Working together with national
    authorities and partners, PEPFAR has supported 70,000 clinics, 3,000
    laboratories and country data systems for surveillance and monitoring,
    and trained over 340,000 health workers. Collectively, this work has
    undergirded the response to infectious diseases and the associated
    morbidity and mortality among the population at large. We must also
    seriously address the all too often unmet need to screen for and treat
    the diseases that are now taking the lives of HIV positive patients on
    ARVs, including hypertension, diabetes mellitus and coronary heart
    disease, as we have done for cervical cancer.
        In the long run, it is the responsibility of each country and its
    Ministry of Health to address the health needs of its population, and
    tremendous progress has been made towards overcoming HIV/AIDS in
    countries where PEPFAR is active. All PEPFAR-supported countries are
    making concrete progress towards sustainability. The level of funding
    countries has invested in their own response to HIV increased to 56
    percent of all funding in 2020. As an example, in South Africa, the
    country with Africa's largest number of people living with HIV, 7.5
    million--of whom 5.5 million are on ARVs paid for by the government.
    South Africa also funds 80 percent of its HIV/AIDS response. Nigeria
    funds almost 80 percent and Botswana funds approximately 50 percent.
    The path towards a sustainable national response has risen from a model
    of partnerships, with country ownership being at its heart.
        Building partnerships by bringing stakeholders to the table is the
    key driver of long-term success. With PEPFAR, host country governments,
    the private sector, faith-based organizations, multilateral
    institutions, civil society and communities of people living with HIV
    have come together in new ways to work towards a coordinated, effective
    response. Ambassador Nkengasong has put partnerships and sustainability
    of national responses at the center of PEPFAR's 5-year strategy,
    ``Fulfilling America's Promise to End the HIV/AIDS Pandemic by 2030.''
        It is through partnerships that programs to prevent mother-to-child
    HIV transmission (PMTCT) have been hugely successful, with healthy
    babies born and spared the tragedy of pediatric AIDS. And thanks to
    PEPFAR's Orphans and Vulnerable (OVC) treatment expansion program, the
    number of children who have lost one or both parents due to AIDS has
    nearly been cut in half since the high point of 1.8 million children in
    2010. Remarkable partnerships have been formed to screen women for
    cervical cancer, a major risk for women living with HIV.
        Despite the many gains made in the HIV/AIDS response, there is more
    work to do. AIDS is still the leading cause of death among teens and
    young adults, with adolescent girls and young women disproportionately
    at risk.
        PEPFAR's DREAMS program is a unique public-private partnership
    dedicated to providing girls and young women with opportunities to stay
    in school safely and access prevention services, along with strategies
    to reduce gender-based violence and expand economic opportunities to
    lead better and healthier lives.
        The work that lies ahead rests in ensuring that the partnerships
    PEPFAR has fostered continue to focus on the outcomes that define
    PEPFAR's success--lives saved, infections prevented and strong health
    systems in place to prepare us for the inevitable future pandemics.
        As the former U.S. Global AIDS Coordinator, I am proud of the work
    we did to establish these vital partnerships to ensure that countries
    would reach the ultimate goal of sustainability. We went from an
    emergency phase to one that centered on the ability of countries to
    eventually move and take up to greater country leadership. We were
    laser-focused on our efforts to save lives through smart investments
    and the shared responsibility of all partners to reach the goal of an
    AIDS-free generation. Now, as Director of Global Health Delivery at the
    University of California San Francisco (UCSF) I am continuing to focus
    on the work we started during my time at PEPFAR to bring together the
    skills and talents of academic institutions to support this and next
    generation of health leaders.
        As was true with Ambassador Goosby's work to establish partnerships
    that would enable countries to take care of their people, in the late
    1990's I helped create the Botswana-Harvard Partnership through the
    Harvard AIDS Institute, in partnership with the Government of Botswana.
    This partnership also was initially formed with the Bristol Myers
    Squibb Foundation and then expanded to involve the Merck and Bill &
    Melinda Gates Foundations, with a focus on scaling up HIV/AIDS care,
    treatment and prevention nationwide. Later, I was fortunate to work
    with multiple African governments, leading the U.S. side of the PEPFAR
    partnerships in Botswana and in five other African countries for over
    10 years. I have seen first-hand how PEPFAR's HIV/AIDS prevention and
    treatment services were literally lifesaving, with hospitals emptying
    as people returned to their families and workplaces. Now, as director
    of Rutgers Global Health Institute, my colleagues and I are able to
    build on the stronger health systems created by PEPFAR in many
    developing countries, helping to address both HIV/AIDS and other
    infectious and noncommunicable disease threats around the world.
        We applaud the leadership of Chairman Menendez, Ranking Member
    Risch, Subcommittee Chairman Booker and all Senators on the Senate
    Foreign Relations Committee who have recognized that PEPFAR, as the
    largest global health program in the world, is an investment that has
    achieved extraordinary results. We also applaud the fact that they are
    champions in working to ensure, through reauthorizing PEPFAR, that its
    vital work continues. Much important work remains.
        We strongly support Ambassador Nkengasong's call to accelerate
    progress in reducing new infections, working together with countries
    and partners to strengthen health systems, and ensuring HIV/AIDS gains
    continue while also leveraging PEPFAR as a critical backbone of
    pandemic preparedness and response.
        When PEPFAR was launched it brought hope to millions. PEPFAR must
    remain this beacon of hope. With the leadership and continued
    commitment from this Congress, it will.

        The Chairman. Thank you, Dr. Dybul. Thank you both for your
    testimony. We will go through a round of 5-minute questions.
        Sir Elton, hopefully we got--we still have you online. I
    had an opportunity to visit some of the sites supported by your
    foundation in South Africa. The Foundation's work with youth
    has really been transformative.
        What are some of the unique challenges that are faced by
    adolescent boys and girls in assessing prevention care and
    treatment services, and from your experiences of the foundation
    is there anything you can recommend that that we need to do to
    overcome those challenges?
        Sir Elton. Well, thank you, Senator.
        Most teens are not connected to the healthcare system and
    they think it is for old and sick people, basically, and not
    for them.
        As we do with all age groups, we need to work with young
    people to develop messages that are meaningful and relevant to
    them and engage youth where they already are, in this case,
    online, as well as in sports, music, and other youth-focused
    events.
        There is no point in designing services that do not get
    used because they do not work for a particular group. Young
    people have a saying, ``Nothing is for us without us,'' and
    that makes sense to me.
        It is so important that you engage the youth of Africa with
    where they are. As I said, online and, on their phones is the
    best way of getting to them and they listen. It has been proven
    that when we do things like that, they listen.
        That is what we are trying to do is to get more programs
    out in the field that can get people on their phones and then
    they talk to each other, and it helps get rid of the stigma.
        Whenever you talk about an issue, it does not seem as bad
    as it is, especially when you are talking with someone of your
    same age group.
        I remember many years ago when we went to Cape Town and
    established the first helpline on Cape Town University where
    people who were afraid of saying they were HIV positive because
    of their families and the university. We set up a helpline that
    they could phone other people and talk about their infections
    and it was a great relief.
        If you inform the young and give them a message and they
    can communicate with each other, it will be fantastic. The most
    powerful tool for someone who is struggling or afraid is #MeToo
    and I know that firsthand.
        My foundation funded a program called Zvandiri in Zimbabwe.
    It means ``taken as I am.'' Youth living with HIV go on into
    their communities and connect with young people like them who
    need advice and HIV testing and treatment.
        The program has been recognized by the World Health
    Organization and UNICEF, funded by PEPFAR with a 5-year game
    changer grant scaled countrywide in Zimbabwe and replicated in
    nine other African countries.
        Young people are amazing. We just need to give them the
    tools to help them help each other.
        The Chairman. Well, thank you. Thank you very much. I saw
    some of those tools at work when we were in South Africa.
        Dr. Dybul, the anecdote that you shared in your testimony
    about hearing the clinic director in Axum, Ethiopia saying
    PEPFAR means the American people care about us is incredibly
    powerful, especially as how we distinguish ourselves against
    strategic competitors around the world.
        Do you think we are effectively messaging PEPFAR as a
    program provided by the American people as a commitment to
    saving lives and ending this pandemic with no strings attached?
        Dr. Dybul. Thank you, Mr. Chairman. It is an excellent
    question.
        I believe we are doing a great job, but it could be better
    and I think Ambassador Nkengasong is the perfect person to
    deliver that message. He has heads of state on speed dial from
    his role as head of Africa's CDC leading the COVID response.
        He is known by ministers throughout the continent. It is
    well known. It is well understood, but I think we can do even
    better and Ambassador Nkengasong will be able to deliver that
    for us and it is absolutely essential because we are in a
    struggle and we need to show the American people's heart and
    our values, which PEPFAR does.
        The Chairman. Thank you.
        Senator Risch.
        Senator Risch. Dr. Dybul, one of the things that we always
    struggle with up here is the bureaucracy and you have been at
    this from the beginning and have a lot more experience than
    anybody in this room probably on that particular issue.
        I want to ask you your thoughts on how important it is to
    have a single accountable entity at the Department of State
    coordinating the activities of PEPFAR's implementing agencies,
    particularly as to USAID and CDC, which occasionally have
    differences.
        Could you--the kindest way I can say it--could you comment
    on that, please?
        Dr. Dybul. Yes. Thank you, Senator Risch.
        I have to say, having had the job it was--is absolutely
    essential. Without a single responsible person who determines
    how the resources are allocated, it is very difficult to move
    things--that piece. Now, that was then.
        We still need it and it maintains the impact of the
    program. By running it through the State Department it also
    contributes to what Chairman Menendez was talking about because
    it is seen as part of the entire U.S. Government, not
    individual agencies.
        That founding piece, which we kind of stumbled on, to be
    honest, was absolutely essential to discuss success of PEPFAR.
    It remains essential to the success of PEPFAR.
        Senator Risch. Well, thank you for that and I assume that
    is advice as much as anything else. We will endeavor to follow
    that advice and appreciate you for the work you have done on
    this.
        Thank you, Mr. Chairman.
        The Chairman. Senator Kaine.
        Senator Kaine. Thank you, Mr. Chair, and just add my
    congratulatory comments, and thanks to Sir Elton for the
    passion and the work that you have done through your
    foundation, using your own reputation around the world to
    really advance, and we appreciate this.
        Dr. Dybul, I want to ask questions of you that were similar
    to those that I asked the previous witness about the Latin
    American reality.
        I am the chairman of the Western Hemisphere Subcommittee of
    this committee, and it just seems like often when we are in the
    public health space we are sort of not paying sufficient
    attention to Latin America--just using COVID as an example.
        The chair and I were advocating strongly that the
    Administration really prioritize Latin America in terms of
    COVID vaccine distribution and what we did was, we did about 8
    percent of our vaccine distribution to Latin America.
        About 8 percent of the global population is in Latin
    America, but 30 percent of deaths were in Latin America, and
    the migration of Latin Americans to the U.S. back and forth
    also created a greater risk of public health infection
    transmission. We felt like those stats--those kind of facts on
    the ground really warranted a more robust allocation in Latin
    America that was not the case.
        Here, I am troubled by the stats showing that while global
    infections are dropping by 32 percent from 2010 to 2021, and
    even infections in the Caribbean, thank goodness, are dropping
    in the mid to high twenties, the infection rate in Latin
    America is increasing by about 5 percent.
        Why is this happening, and what more can we do to
    prioritize really going after this battle and succeeding in
    Latin America?
        Dr. Dybul. It is an excellent question, Senator Kaine, and
    it is one that I have struggled with both when I was at PEPFAR
    and then at the Global Fund, which has a fairly large presence
    in Latin America as well and, in fact, what you point out in
    the Caribbean, I think, is largely because of the engagement of
    PEPFAR, which has always been heavy in the Caribbean and less
    so in deeper Latin America.
        Brazil had a very strong program at the beginning, but then
    it collapsed a bit, and I think what you are pointing to has a
    lot to do with the political instability we are seeing in Latin
    America and the shifts in governments and the shifts in
    prioritization which used to focus more on health.
        It is complicated because there tend to be higher income
    countries and so foreign assistance money is often not seen or
    used in the same way.
        As Ambassador Nkengasong said, we can still play a role and
    the role we can play is at the political level, but also at the
    higher systems level and at the International Development Bank
    level to use our capacity to support with fairly small amounts
    of money those community-based links that will reach the people
    in need.
        Also, in Latin America, as in Africa, we have seen younger
    people forgetting about HIV because they are--they do not see
    everyone dying anymore and you are seeing marginalized groups,
    for example, in the Amazon region that are affected.
        We can respond. It will just be different because of the
    high income nature of the countries, but if we engage there, I
    think we can see a difference as we have seen in the Caribbean.
        Senator Kaine. I will just say this and conclude. I know
    the chairman and I are both focused on this. A number of the
    programs that we have whether through USAID or other
    international accounts put income limitations. You can go to
    countries and they might have a high income under some median
    measure and yet you find deep and intense poverty and
    incredible isolation in communities. I worry sometimes that
    just taking a rough cut with a median income figure does not
    really do justice to needs and particularly in our own region.
    I think there can--there is just so much good to be gained by
    the U.S. being more engaged, not less.
        I want to continue to work with my committee colleagues on
    that, but thank you for that answer. I yield back, Mr. Chair.
        The Chairman. Thank you, Senator Kaine. I share your
    concern. I think we are being locked out of a lot of
    opportunities to help our southern neighbors and help ourselves
    in the context and we look forward to working with you to see
    if we can find a better pathway forward and I appreciate your
    focus on the hemisphere.
        Senator--Dr. Barrasso.
        Senator Barrasso. Thanks so much, Mr. Chairman.
        Sir Elton, thanks for all of your work on this. I know you
    have had bipartisan cooperation. I know you have been recently
    with Chris Coons and Lindsey Graham in our efforts on this.
        Could you talk a little bit about what is happening with
    private donors following COVID-19? Are you seeing any decrease
    in the private donations to this effort here and given the
    current state of the economy? What strategy do you have working
    with others to increase the funding?
        Sir Elton. Well, I think--thank you, Senator. I think we
    are seeing a decrease in private donors, which is dismaying,
    but there are a lot of other diseases around, and sometimes
    AIDS falls into the background. We have had COVID to deal with.
        I am confident that we can turn that around. That is why
    PEPFAR is really so important because when people see that this
    is working so well I think the private donors will get back on
    board.
        We are doing everything we can to because we rely as a
    foundation on private donors, and so far it really has not
    affected us so much as an organization, as an AIDS foundation,
    because I think we do really great work and people know that we
    are reliable.
        In general, we have to get people back on board and that is
    why PEPFAR is the shining light in all of this, and HIV funding
    is being used for COVID as well. I mean, it is just a no-
    brainer. We just have to put our feet in the sand and say,
    right, this is going down at the moment, but we can pick it
    back up.
        It has not affected the AIDS Foundation, but it has
    affected funding in general, I think, for every kind of charity
    on health--regarding health. Am I optimistic? Well, I am always
    optimistic, but it is because of you guys out there that I am
    optimistic. Thank you.
        Senator Barrasso. Thank you.
        For Dr. Dybul and then for Sir Elton as well, kind of
    looking forward the next 5 years what do you see as some of the
    challenges plus opportunities for PEPFAR?
        Dr. Dybul. Thank you, Senator Barrasso and--Dr. Barrasso,
    as a fellow physician. The challenges will be two-fold, one
    financial, and secondly, lack of interest or shifting focus--
    other pandemics.
        However, the best way to respond to future pandemics is to
    fight current pandemics and build the capacity so that you have
    that surge capacity, and there is the opportunity. We actually
    have the opportunity to get people to focus on pandemics in a
    way that was--we were moving away from, but COVID could bring
    us back to and that is where the opportunity is.
        The other opportunity, I think, relates to what was
    discussed earlier on localization. There is enormous talent
    capacity at the community level, which relates to the
    diplomatic benefits.
        We can actually reach to community level to shape hearts
    and minds and to introduce them again to the United States and
    our values, which are better values than the--what others are
    offering. I think there is lots of opportunity for us on
    multiple levels.
        Senator Barrasso. Thank you.
        Sir Elton.
        Sir Elton. I think stigma and discrimination--shame stops
    progress and this is what we are finding in America as well. We
    must stop this. We must get the opportunity in the hands of
    young people to stop this.
        Stigma is always a challenge--we have the medicine here to
    shut this disease down, which is truly amazing, but it is the
    stigma that stops the progress, and the shame.
        As I say, I am optimistic and I think with young people, if
    you give young people the gauntlet they will run with it.
    Criminalization of LGBT people affects progress as well in
    certain countries.
        We mentioned Uganda earlier on in forum, and it is
    dismaying to see this. It hinders not only people who have to
    go underground, but it is inhumane and it will eventually
    hinder their economy and the global economy and it is just a
    dead-end situation.
        As I have said, I am optimistic, but we have a lot of work
    to do. We are not just sitting here clapping our hands. We have
    a hell of a lot of work to do.
        Having seen how you guys today--you senators have come
    together, I am so moved by your enthusiasm, your commitment.
    When you get a life force like PEPFAR, I think is like that
    ball that came down in Indiana Jones or ``Raiders of the Lost
    Ark.''
        It is an immovable force, and having seen what you senators
    have to say--I call you guys, sorry--you senators have to say
    today and your intelligence and your commitment behind this
    incredible PEPFAR organization that has done so much. I feel so
    moved to do even more than I am at this present moment in time.
        It is an inspirational thing, as I said in my speech
    before, and I think together we can get rid of this disease. I
    really believe that, but we have a lot of work to do, and you
    guys are doing a hell of a lot of work in there and in the
    background, and you are full of intelligent questions and you
    have done your homework.
        Now, if we do the homework together, we can stop it. We
    actually can. Thank you for all you do. Thank you for your
    wonderful time and effort today.
        Senator Barrasso. Thanks to both of you. Thank you, Mr.
    Chairman.
        The Chairman. Sir Elton, we have been called worse than
    ``you guys.''
        [Laughter.]
        The Chairman. Senator Booker.
        Senator Booker. For the record, I would like a Mother's Day
    card. I have been called ``mother'' so many times followed by
    something else.
        [Laughter.]
        Senator Booker. Dr. Dybul, I appreciate all your leadership
    and work. Senator Menendez made a very insightful point about
    the efforts--really encouraging efforts to get a clean
    reauthorization, but if there were any changes in the program,
    is there anything that you would see that could help us to even
    improve our efforts?
        Dr. Dybul. Thank you, Senator Booker.
        Having been involved since the beginning and actually being
    one of the architects of the original plan you approved in
    2003, I do not think they are--I think the 2008 reauthorization
    did everything that needed to be done and a clean
    reauthorization is fine.
        Report language around issues that are important to you
    help steer the Administration, but as a piece of legislation, I
    do not think there is anything that needs to be changed in the
    legislation itself.
        Senator Booker. Are there some things that concern you that
    you hear people calling for that would be bad if it got into
    the--a reauthorization?
        Dr. Dybul. You always hear rumors in this town as part of
    the job and so there are things out there you hear. I think the
    biggest risk or dangers opening up for conversations the
    chairman mentioned and the ranking member endorsed that we just
    keep relitigating the same things over and over again and the
    legislation as it is is actually not just fine; it is
    excellent. It has served well for 20 years.
        Senator Booker. You heard my concerns earlier about,
    obviously, the effort with COVID, I think, educated a lot of
    people about how co-morbidities contribute to death and,
    obviously, that is the same thing with HIV and AIDS.
        Are there some strategies that we are using to deal with
    other--TB and other challenges that are going to help us with
    this effort?
        Dr. Dybul. Definitely, and tuberculosis has actually been
    part of PEPFAR from the beginning because it is one of the
    leading causes of death, but in Africa, as in the United States
    people are living. People have now been on drugs for 20 years
    in Africa. They are in their fifties. They have co-morbid
    conditions, and that is the importance of the systems that have
    been built--the health systems that have been built and, again,
    I go back to this is a chronic disease like heart disease,
    diabetes. It is not like tuberculosis or malaria. You have to
    take drugs your entire life.
        Prevention is a lifelong activity. You are at risk for HIV
    your entire life so the behavioral issues and things that we
    have to deal with, with diabetes, hypertension, and other
    noncommunicable diseases, as we call them, actually PEPFAR was
    built for that and the systems were built for that because it
    is a chronic disease.
        I think the pieces are there and we just need to use them
    and I think we are using them. Countries are using them wisely
    as we move from isolated HIV programs to something that is, in
    fact, part of the health system itself.
        Senator Booker. Sir Elton John mentioned in a really
    tactical way about how you get to this new generation that is
    growing up when you do have people living for 50 years not in
    an atmosphere where the fear sears into you a sense of urgency,
    and maybe the young people are not taking it as seriously as
    possible.
        Meeting them where they are on social media and more--I was
    happy to hear Sir Elton John and his focus on this, but there
    is another group that still causes concern for me that are
    younger, young girls in particular, which I think necessitates
    other tactics as well.
        Could you mention some of those?
        Dr. Dybul. Yes. In fact, PEPFAR and the Global Fund and
    actually are deeply engaged there. There are structural issues
    related to young girls, their menstrual period, for example,
    and how--what they do and do not have access to in schools that
    affects HIV.
        Abuse--sexual abuse is a major problem that leads to
    transmission of HIV because the woman cannot protect herself,
    and so that is where some of the new therapies--long-acting
    injectables, for example--could allow women to prevent HIV as a
    prophylactic.
        Instead of taking pills--PrEP--you can do an injectable
    that will last for 3 months, which actually happens to match
    family planning injectables.
        There are a lot of things coming and--but going back to the
    legislation that can all be done within the current
    legislation, but dealing with young girls is a major issue--a
    structural issue--and there has been a lot of progress, but a
    lot more needs to be done and it involves some medical
    intervention, but also behavioral interventions. There has been
    significant change.
        We have seen it and the DREAMS program and other programs
    that the United States has supported help, but we have to take
    that bigger picture.
        It is not just medical. It has to do with societal and
    behavioral issues, but it is changing and the United States has
    played a significant part in that change.
        Senator Booker. Thank you very much to both of our
    witnesses.
        Mr. Chairman.
        The Chairman. Senator Van Hollen.
        Senator Van Hollen. Thank you, Mr. Chairman, and let me
    thank both of our witnesses who are here today. I was honored
    to be part of a congressional delegation along with Senator
    Menendez, the chairman, as well as Senator Graham and other
    members of the committee to South Africa to celebrate the 20th
    anniversary of the PEPFAR program, a program that more than any
    other public health program, I think, in history has saved
    millions and millions of lives.
        First, Sir Elton John, thank you for your leadership. It
    was good to have a chance to meet and talk with you and your
    team during our visit to South Africa.
        I have been bouncing between hearings so you may have
    covered this, but as my friend, Senator Booker said, because of
    the success of the PEPFAR program, you have the younger
    generation of South Africans and others around the world--
    younger generations not seeing AIDS/HIV as a death sentence and
    that is a good thing.
        On the other hand, the question is making sure that we
    provide those young people with the information they need to
    get the help when they need it, and I know you have got an
    active social media program going through Facebook. We talked
    about expanding that to other platforms as well, like
    Instagram.
        Sir Elton John, first, thank you, and then if you could
    just provide us an update on how many young people are
    currently using the platform, what you see is the future of the
    platform, and I should say that we had a chance to meet with
    some of the young people that were using it while we were
    there.
        It is off to a good start. How do you see the future of
    that social media program?
        Sir Elton. I am very optimistic because God knows the
    internet is responsible for so many awful things, but it can
    also be responsible for so many wonderful things and the
    wonderful thing it can do is we provide young people with
    information to stay healthy, services like HIV testing,
    treatment, PrEP, mental health services, and more.
        It is really important to get online services to young
    people where they need it, not them have to travel, but they
    need to get it locally, and expanding programs across multiple
    countries and linked to health systems and it is going really,
    really well.
        I think we have, hopefully, nearly 100,000 people using
    this now and when we were in South Africa about 30,000 were
    using it, so it is coming along very well and it is nice to see
    you again after our wonderful trip.
        My adamant thing is use the internet to get to the young.
    The young are taking this up and they really are responding to
    the information and the fact that they can talk to each other
    online about it or on their phone is really, really important
    and they are the future.
        They are our future no matter what it was, whether it is
    HIV, the world, or whatever. The young people are the ones that
    are going to take this forward and they are responding to it
    and that is a great sign.
        Senator Van Hollen. Well, thank you. As you said, the way
    to connect with so many of these young people is to meet them
    where they are on social media and we know that there is a huge
    take up of social media in South Africa and so many of these
    other countries. Thank you for all those efforts--your
    continuing efforts.
        Dr. Dybul, one of the goals of the HIV/AIDS program--that
    PEPFAR program--has been to make it sustainable over time and
    we have wanted to work with governments to transition more and
    more responsibility to those national governments.
        Some partner countries have demonstrated both the political
    will, as well as the capacity to take ownership of managing.
    Some of them have taken on a larger and larger share of the
    budgets for administering the program.
        Other countries have not shown the political will nor
    provided the budget support for the program. Can you talk about
    how we navigate that and how we continue to support the
    countries that are trying to take responsibility, but also how
    we address those countries that have not?
        Dr. Dybul. It is an excellent question, Senator, and it is
    one that all international organizations struggle with. I think
    PEPFAR has probably done as well or better than any ever have,
    as you pointed out.
        For the countries that are not moving, and here again I go
    back to Ambassador Nkengasong will be the best Global AIDS
    Coordinator of any of us by far.
        He has the capacity, the contacts, the ability to move that
    in ways that I do not think any of the rest of us could and
    part of that is from his time as Africa's CDC director, but
    also before that when he was leading the laboratory effort in
    Africa for PEPFAR.
        It is a complex issue that involves political, but also
    ground--top level political, but also ground up forcing,
    pushing and we have been doing some of this work, actually.
    PEPFAR has been doing this work to build that strong community
    push for health services to the government and it is actually
    worked in Kenya and Eswatini and other places.
        We have seen governors double, triple their budgets because
    of the ground up pressure, not because of the external
    pressure, and so some of it is the political engagement, but it
    is also supporting those community groups where it goes back to
    some of the localization that then puts pressure on the
    governments to step up healthcare because it is good politics
    for them.
        I have that conversation with heads of state. I used to
    bore them to tears with statistics and I learned to start off
    saying health is good politics. They get that in a second and
    then you can play that out.
        Senator Van Hollen. Well, thank you. I appreciate that, and
    you mentioned Dr. Nkengasong and I am sorry I was not able to
    make his testimony.
        I know this is an area he is focused on and appreciate your
    laying out the challenges and as well, but I think you hit it
    on the head, which is to make sure that leaders in those
    countries understand that this is a good thing for their public
    and a good thing for their own politics as well.
        Thank you.
        The Chairman. Thank you.
        Senator Coons.
        Senator Coons. Thank you, Chairman Menendez, Ranking Member
    Risch.
        Thank you, Chairman Menendez, for the opportunity to travel
    with you to southern Africa and in particular to South Africa
    with Sir Elton John and Dr. Nkengasong to celebrate the 20th
    anniversary of this landmark program that has saved more than
    25 million lives, I think the single best thing President Bush
    did, I think something that has been sustained over
    presidencies and majorities of both parties.
        I was just at a hearing with the administrator of USAID.
    One of the significant portions of this year's budget request
    is to sustain and extend our PEPFAR investment, our investment
    in transforming public health systems around the developing
    world.
        Sir Elton John, it is great to see you again. It was
    wonderful to get some time with you and to see the connection
    that you are able to create and sustain with young people and
    the services that your foundation is helping facilitate and
    scale for young people online is a great investment and an
    encouraging story.
        If I could, Mr. Dybul, I just would be interested--I have
    missed most of the hearing and I suspect you have covered
    this--what you think are the areas where we most need to invest
    in innovation, in policy.
        As many countries are transitioning towards epidemic
    control we need to better understand what our sustained
    investment in PEPFAR will accomplish and what are the key
    challenges to moving towards an AIDS-free generation.
        Dr. Dybul. Thank you, Senator Coons. In terms of
    innovation, there are many areas of innovation. There is
    scientific innovation, for example, the long-acting, anti-
    virals that I mentioned, which could be prophylactic, but also
    a treatment potentially; better diagnostics, local diagnostics,
    so people can be diagnosed and treated rapidly, which we think
    would then reduce the transmission.
        The innovation that we really need relates to localization,
    which I am sure came up in your conversation with
    Administrative Power. Reaching communities and sustaining those
    communities, funding those communities--the faith communities,
    the community-based organizations--that will not only enhance
    our ability to reach those most at risk because that is where
    they are in the communities, but will also then give us the
    ability to detect and respond to the next pandemic threat.
        The innovation, some of that is technological and how
    people connect with each other, but some of it is just human-
    to-human innovation and this is a fundamental area. Most of the
    innovation that we have seen in PEPFAR and Global Fund and
    other development programs comes from the individuals. We can
    say go do X, Y, or Z. They figure out in a setting with almost
    no resources how to make that work.
        Supporting that innovation will do two things--one, lead to
    greater success, and two, provide that ground up pressure for
    change that will not only be related to health, but
    democratization and many other things.
        The challenges will be financing, the challenges will be
    distraction from--to other things, and the challenge will be
    global competition for whose voice are they listening to, and I
    think the United States is well-positioned and PEPFAR has put
    us in a position to be able to do that extraordinarily well.
        Senator Coons. Last question, if I might. I just spent
    several days at a retreat looking at nutrition and food
    security in particular. I assume there are overlaps--Dr.
    Nkengasong may agree--because those who are immunocompromised,
    those who are most at risk of infection, those who are living
    with HIV/AIDS, also need sustained high-quality food and
    nutrition.
        There is a food as medicine movement that I have been
    trying to better understand and this is one population, or one
    area of focus, those who are at risk, where I think our work in
    strengthening food systems can learn a lot from the
    groundbreaking work that PEPFAR has done in strengthening and
    transforming public health systems, particularly in rural
    communities, particularly in communities where food security is
    also aligned with being at risk for new infections.
        I look forward to staying in touch. Thank you, Mr.
    Chairman, for allowing me to question here at the very end and,
    again, to both Sir Elton John and to Dr. Nkengasong, thank you
    for your engagement and leadership in this area.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Coons. Thank you for your
    work, particularly on the Appropriations Committee. It is
    incredibly important.
        I want to thank our witnesses for appearing before the
    committee and for speaking with such knowledge and passion
    about PEPFAR and the fight against HIV/AIDS.
        I think it is appropriate to recognize President George W.
    Bush for his leadership and vision over 20 years ago. Some may
    not have thought that it would be possible to achieve what we
    achieved today, but it was his leadership at that time that
    began us on this course so it is appropriate and fitting to
    recognize it.
        I think we can all agree that PEPFAR shows the
    extraordinary power of American determination, compassion, and
    ingenuity marshaled for the purpose of making the world a
    better place.
        I look forward to working with my colleagues across
    Congress, with the Administration, with experts and advocates
    to ensure that PEPFAR is equipped to continue its mission to
    end the HIV/AIDS epidemic.
        I asked unanimous consent at this time to enter testimony
    for the hearing record from former Global AIDS Coordinator, Dr.
    Eric Goosby, and founding director of Rutgers Global Health
    Institute, Dr. Richard Marlink, and ask that it appear
    immediately after the testimony offered by our witnesses on our
    second panel.
        Without objection, so ordered.

    [Editor's note.--The information referred to above can be found
    immediately following the ``Prepared Statement of Dr. Mark
    Dybul'' in this hearing.]

        The Chairman. Sir Elton, we wish you good luck on your
    world tour. I know it will be a smash, and thank you again for
    joining us virtually from across the pond.
        Dr. Dybul, thank you for your extraordinary leadership over
    this period of time.
        The record for this hearing will remain open until the
    close of business on Thursday, April 20. Please ensure that
    questions for the record are submitted no later than that date.
        With that and with the thanks of the committee, this
    hearing is adjourned.
        [Whereupon, at 11:42 a.m., the hearing was adjourned.]
                                  ----------

                  Additional Material Submitted for the Record

                 Responses of Dr. John Nkengasong to Questions
                       Submitted by Senator Bill Hagerty

        Question. How do you assess the ways in which PEPFAR contributes to
    overall U.S. foreign policy goals with respect to recipient countries,
    including U.S. diplomatic, economic, and security objectives? What
    metrics do you use to measure these linkages and impacts?

        Answer. PEPFAR has continued to be an expression of U.S. values and
    demonstrates our deep commitment to health security and prosperity
    globally. It is one of our strongest foreign policy tools in partner
    nations, helping to advance all our diplomatic, economic, and security
    objectives, directly and indirectly. PEPFAR's impact on our diplomatic
    efforts is immeasurable, strengthening partnerships for over 20 years.
    PEPFAR has also played a direct role in saving lives, increasing GDP,
    and in some countries, ensuring the readiness of Armed Forces for UN
    peacekeeping missions.

        Question. How does PEPFAR integrate with broader U.S. public
    diplomacy efforts in recipient countries? What quantitative and
    qualitative data does PEPFAR collect on the impact of its programs on
    public perceptions of the United States in recipient countries?

        Answer. PEPFAR programs in all countries fall under the direct
    authority of U.S. Ambassadors, and PEPFAR Program Coordinators residing
    in-country report to the Deputy Chief of Mission or Ambassador. In some
    countries, PEPFAR employs communications staff, but works in tandem
    with embassies' Public Affairs offices that have primary responsibility
    for public affairs and public diplomacy programs in recipient nations.
    Independent entities such as the Kaiser Family foundation conduct such
    assessments of PEPFAR's impact.

        Question. Under what conditions will PEPFAR be able to claim it has
    largely eradicated HIV/AIDS? When do you anticipate these conditions
    will be met?

        Answer. Our focus is on the goal of ending the HIV/AIDS as a public
    health threat by 2030, a state where new HIV infections and mortality
    of PLHIV have dramatically declined. The millions of people living with
    HIV will continue to need ongoing HIV treatment. Eradicating HIV is not
    possible without a vaccine. Controlling the HIV pandemic with high
    coverage of effective antiretroviral therapy (ART), pre-exposure
    prophylaxis (PrEP) and other prevention interventions is possible. The
    use of data, HIV testing, treatment and prevention strategies will
    continue to evolve.

        Question. PEPFAR's funding request has steadily increased over
    time. Under what conditions would the program require less resourcing
    to accomplish its goals?

        Answer. While PEPFAR funding has increased over the past decade,
    those increases have not kept pace with inflation. Additionally, there
    are costs to transitioning programs from a scale up mode to a
    sustainment mode, as well as some additional costs required to find the
    hardest to reach populations. As countries near epidemic control, we
    will continue to evaluate what is needed to sustain those HIV gains in
    consultation with Congress and host-country governments.

        Question. How is PEPFAR working to improve domestic resource
    mobilization in recipient countries? Specifically, how is the program
    working to strengthen local health systems, so they are sustainable
    without foreign assistance?

        Answer. PEPFAR has always invested in host government systems and
    capabilities, as can be seen in the COVID-19 response, which depended
    heavily on HIV systems. Over the next year each country will develop a
    measurable Sustainability Roadmap that will document responsibility for
    the development of core government systems and functions and a
    financing component that supports the capabilities the PEPFAR program
    invests in. Over time responsibility for treatment and prevention
    programs will also be transitioned.

        Question. How do changes in the epidemiological landscape--such as
    a decline in HIV/AIDS--affect funding requirements for recipient
    counties?

        Answer. PEPFAR has saved more than 25 million lives and prevented
    millions more new infections. This vital mission should be continued,
    expanded and shared with other donor and partner countries. As
    countries near epidemic control and PEPFAR continues to engage partner
    governments on the sustainability of the HIV response, we will continue
    to evaluate what is needed to sustain those HIV gains both from a
    financial and programmatic standpoint in a country-specific manner.

        Question. How does PEPFAR programming complement the efforts of the
    Global Fund? Are there areas in which PEPFAR duplicates the efforts of
    the Global Fund?

        Answer. PEPFAR works in close coordination and collaboration with
    the Global Fund on all levels (at headquarters, regionally and in
    country) to ensure our efforts are well-aligned and complimentary. The
    PEPFAR Country Operational Planning (COP) co-planning process
    incorporates staff from the Global Fund to ensure joint programming
    with the country. At the country level, PEPFAR participates in the
    Global Fund's Country Coordinating Mechanisms. At headquarters, PEPFAR
    implements resource alignment activities to deduplicate jointly funded
    areas.

        Question. What percentage of global HIV/AIDS pandemic assistance is
    conducted by PEPFAR compared to the Global Fund and other initiatives?

        Answer. Globally, most HIV-specific funding comes from PEPFAR and
    the Global Fund. Of total HIV funding, PEPFAR has a program level of
    about $4.5 billion and the Global Fund about $2.1 billion for HIV,
    including $1.95 billion in PEPFAR funded countries. PEPFAR and the
    Global Fund have detailed aligned data on spending in countries where
    both programs operate. There are also initiatives from other donors and
    multilateral development banks that make important investments in
    health systems and health financing that amplify the HIV effort but are
    not HIV specific.

        Question. Why do you believe PEPFAR has been so successful in
    moving toward localization? What lessons can be drawn for other U.S.
    foreign assistance programs?

        Answer. In the first few years of PEPFAR, there was limited local
    capacity to provide HIV treatment and prevention services. Over the
    past 20 years, PEPFAR has made tremendous progress building national
    capacity to implement, while gaining experience through the ``Track 1
    transition'' which identified how to manage and effectively implement
    clinical services through local partners. PEPFAR has also continued to
    invest meaningful time and effort to increase the depth and breadth of
    the financial and operational data we collect on partners to improve
    our oversight and prevent any fraud, waste and abuse.

        Question. What barriers remains to full localization of PEPFAR
    programming?

        Answer. There is still need for local organizations to scale up
    their programming in many PEPFAR-supported countries. To do so will
    require effectively assessing the technical and operational
    capabilities of our local partners and helping to support them to
    strengthen those underlying capabilities so they can manage a portfolio
    of services. There will also be an ongoing need for international
    organizations to provide targeted expertise, especially to deploy new
    innovations and share global best practices.

        Question. What implications does localization have for PEPFAR's
    overall costs?

        Answer. Localization does have potential to lower overall costs.
    However, the cost savings will be more modest than it may appear. For
    example, most staff of implementing partners are already locally
    employed and there are unavoidable costs of doing business when working
    with the U.S. Government around reporting requirements and systems. To
    the extent that PEPFAR uses local government systems there is the
    potential for more robust savings, but those savings must be weighed
    against the risks that government-to-government arrangements bring.

        Question. How does PEPFAR navigate the challenge or vetting and
    measuring the performance of local implementing partners rather than
    larger international organizations?

        Answer. PEPFAR uses the same high standards for both initially
    vetting the qualifications of any partner, international or local, as
    well as the performance management during the contract. In our planning
    process, every partner is aligned with specific measures of performance
    for the services they have been enlisted to provide and those
    performance indicators are tracked quarterly during implementation and
    steps are taken to remediate any issues with performance if they exist.

        Question. How does USAID conduct the vetting of local implementing
    partners to ensure any funding is consistent with the Helms Amendment
    and other restrictions?

        Answer. PEPFAR has the oversight mechanisms in place which seek to
    ensure that PEPFAR funds, including funds provided to USAID, are
    implemented in a manner consistent with all applicable federal
    statutory restrictions, including those related to the Helms Amendment.
    We work with and provide guidance to our implementing partners on
    implementation of these requirements and implement partner management
    activities through our USG staff at our embassies.
                                     ______

           Statement From David J. Kramer, George W. Bush Institute,
                              Dated April 19, 2023

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